Citation Nr: 18158318 Decision Date: 12/14/18 Archive Date: 12/14/18 DOCKET NO. 16-43 330 DATE: December 14, 2018 REMANDED Entitlement to service connection for a low back disability, claimed as inflammation of the back and body is remanded. Entitlement to service connection for a left hand disability, claimed as inflammation of the left hand is remanded. Entitlement to service connection for a right hand disability, claimed as inflammation of the right hand is remanded. Entitlement to service connection for a low immune condition is remanded. Entitlement to service connection for food and airborne allergies is remanded. Entitlement to service connection for low blood pressure is remanded. Entitlement to service connection for chronic headaches is remanded. Entitlement to service connection for a sleep disorder, claimed as due to inflammation of the back and body is remanded. Entitlement to an initial rating in excess of 10 percent for a right ankle disability is remanded. Entitlement to an initial compensable rating for chronic bronchitis is remanded. REASONS FOR REMAND The Veteran, who is the appellant in this case, had service from October 1988 to November 1991 and from December 2007 to June 2008. 1. Entitlements to service connection for a low back disability, claimed as inflammation of the back and body, a left and right hand disability, claimed as inflammation of the bilateral hands, a low immune condition, food and airborne allergies, low blood pressure, chronic headaches, and a sleep disorder are remanded. The Veteran received VA examinations for a low back disability, claimed as inflammation of the back and body, a left and right hand disability, claimed as inflammation of the bilateral hands, a low immune condition, food and airborne allergies, low blood pressure, and chronic headaches in September 2016. The VA examiner only rendered opinions on whether the claimed disabilities were related to a Gulf War illness. Furthermore, the same VA examiner found that some of the Veteran’s claimed disabilities (inflammation of the body, low back, and bilateral hands, as well as low blood pressure and unexplained fatigue) were related to her diagnosis for Ehlers-Danlos Syndrome (EDS), which the examiner explained was a genetic disease, but did not opine whether it was a congenital disease that preexisted military service and was aggravated by service. VA’s General Counsel has held that service connection may be granted for diseases (but not defects) of congenital, developmental or familial origin if the evidence as a whole shows manifestations of the disease first in service (incurrence) or that if first manifested prior to service, additional symptoms of the disease in service constituted “aggravation” of the disease within the meaning of applicable VA regulations. VAOPGCPREC 82-90 (July 18, 1990); 38 C.F.R. §§ 3.303(c), 3.306. In addition, a congenital defect can be subject to superimposed disease or injury, and if that superimposed disease or injury occurs during military service, service connection may be warranted for the resultant disability. VAOPGCPREC 82-90. The VA examiner also found that the Veteran’s low immune condition and allergies were related to the diagnosed Mast Cell Activation Disorder (MCAD), but did not provide any rationale or medical nexus opinion for whether MCAD was related to service. A May 2014 private treatment record shows that the Veteran was diagnosed with EDS. The private geneticist noted that the Veteran had joint pain, menorrhagia, and dysautonomia in the form of irritable bowel syndrome (IBS) and paroxysmal orthostatic tachycardia syndrome (POTS). On VA mental health examination in October 2016, the Veteran endorsed onset of sleep issues since service that also may be related to her EDS and MCAD. 2. Entitlements to an initial rating in excess of 10 percent for a right ankle disability and an initial compensable rating for chronic bronchitis are remanded. VA treatment records since October 2016 show that the Veteran endorsed increased worsening of her right ankle disability due to more frequent instances of instability and falls since her last VA examination in July 2016. The evidence also indicates that her bronchitis symptoms may have worsened since her last VA examination in July 2016. A January 2017 VA treatment record shows that the Veteran had bronchitis twice in less than 30 days despite taking prescribed medication and she requested a prescription for a nebulizer. However, the Board is without the expertise necessary to determine the extent of worsened symptoms exhibited by the Veteran’s disabilities. “VA regulations specifically require the performance of a new medical examination ... [when] ‘evidence indicated there has been a material change in a disability or that the current rating may be incorrect.’” Caffrey v. Brown, 6 Vet. App. 377, 381 (quoting 38 C.F.R. § 3.327(a)) (1994). As there is evidence suggesting that the Veteran’s conditions may have worsened since the last VA examinations of record, the Board finds that the Veteran’s claims should be remanded to provide her with updated examinations to accurately assess the current condition of the disabilities. In claims for a rating increase, it is first and foremost a priority to ensure that the most current assessment of the service-connected disability picture is of record. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991). The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from July 2017 to the Present. 2. Obtain an addendum opinion by a physician (M.D.) to determine the nature and etiology of any Ehlers-Danlos Syndrome (EDS), claimed as inflammation of the body, low back, and bilateral hands, as well as low blood pressure, headaches and unexplained fatigue. The examiner is asked to answer the following questions in regard to periods of service from October 1988 to November 1991 and December 2007 to June 2008 (deployed to Iraq): (a.) Does the Veteran’s diagnosed Ehlers-Danlos Syndrome (EDS) constitute a congenital defect or disease? (b.) If the Veteran’s EDS is considered a congenital defect, is it as likely as not that there was a superimposed disease or injury in connection with the congenital defect during the Veteran’s active duty service, to include dust and burn pit exposure in Iraq and/or based on any other medical symptoms endorsed during service? (c.) If EDS is a disease, did it clearly and unmistakably preexist the Veteran’s active duty military service? (d.) If the answer to question (c.) is “yes,” is there also clear and unmistakable evidence that EDS was NOT permanently aggravated beyond its natural progress during service? (e.) If the answer to either question (c.) or (d.) is “no,” assume as true that the Veteran did not enter service with the disability. With this assumption in mind, is it at least as likely as not (i.e., a 50 percent or greater probability) that EDS had its onset in service, or is otherwise related to active service, to include dust and burn pit exposure in Iraq and/or based on any other medical symptoms endorsed during service? The examiner must provide complete rationale for the conclusions reached. 3. Obtain an addendum opinion by a physician (M.D.) to determine the nature and etiology of any Mast Cell Activation Disorder (MCAD), claimed as low immune condition as well as food and airborne allergies. The examiner is asked to answer the following questions in regard to periods of service from October 1988 to November 1991 and December 2007 to June 2008 (deployed to Iraq): (a.) Does the Veteran’s diagnosed Mast Cell Activation Disorder (MCAD) constitute a congenital defect or disease? (b.) If the Veteran’s MCAD is considered a congenital defect, is it as likely as not that there was a superimposed disease or injury in connection with the congenital defect during the Veteran’s active duty service, to include dust and burn pit exposure in Iraq and/or based on any other medical symptoms endorsed during service? (c.) If MCAD is a disease, did it clearly and unmistakably preexist the Veteran’s active duty military service? (d.) If the answer to question (c.) is “yes,” is there also clear and unmistakable evidence that MCAD was NOT permanently aggravated beyond its natural progress during service? (e.) If the answer to either question (c.) or (d.) is “no,” assume as true that the Veteran did not enter service with the disability. With this assumption in mind, is it at least as likely as not (i.e., a 50 percent or greater probability) that MCAD had its onset in service, or is otherwise related to active service, to include dust and burn pit exposure in Iraq and/or based on any other medical symptoms endorsed during service? The examiner must provide complete rationale for the conclusions reached. 4. Obtain an addendum opinion from a physician (M.D.) regarding the Veteran’s claimed low back disability. The examiner must opine on the following in regard to periods of service from October 1988 to November 1991 and December 2007 to June 2008 (deployed to Iraq): (a.) whether it is at least as likely as not related to an in-service injury, event, or disease, to include dust and burn pit exposure in Iraq and/or any other medical symptoms endorsed during service. 5. Obtain an addendum opinion from a physician (M.D.) regarding the Veteran’s claimed hand disability, to include arthritis, carpal tunnel syndrome, and trigger finger. The examiner must opine on the following in regard to periods of service from October 1988 to November 1991 and December 2007 to June 2008 (deployed to Iraq): (a.) whether it is at least as likely as not related to an in-service injury, event, or disease, to include dust and burn pit exposure in Iraq and/or any other medical symptoms endorsed during service. 6. Obtain an addendum opinion from a physician (M.D.) regarding the Veteran’s claimed headache disability. The examiner must opine on the following in regard to periods of service from October 1988 to November 1991 and December 2007 to June 2008 (deployed to Iraq): (a.) whether it is at least as likely as not related to an in-service injury, event, or disease, to include dust and burn pit exposure in Iraq and/or any other medical symptoms endorsed during service. 7. Obtain an addendum opinion from a physician (M.D.) to determine the nature and etiology of any sleep disability. The examiner must opine on the following in regard to periods of service from October 1988 to November 1991 and December 2007 to June 2008 (deployed to Iraq): (a.) whether it is at least as likely as not related to an in-service injury, event, or disease, to include dust and burn pit exposure in Iraq and/or any other medical symptoms endorsed during service. 8. Obtain an addendum opinion from a physician (M.D.) regarding the Veteran’s claimed low blood pressure disability. The examiner must opine on the following in regard to periods of service from October 1988 to November 1991 and December 2007 to June 2008 (deployed to Iraq): (a.) whether it is at least as likely as not related to an in-service injury, event, or disease, to include dust and burn pit exposure in Iraq and/or any other medical symptoms endorsed during service. 9. Obtain an addendum opinion from a physician (M.D.) regarding the Veteran’s claimed low immune condition. The examiner must opine on the following in regard to periods of service from October 1988 to November 1991 and December 2007 to June 2008 (deployed to Iraq): (a.) whether it is at least as likely as not related to an in-service injury, event, or disease, to include dust and burn pit exposure in Iraq and/or any other medical symptoms endorsed during service. 10. Obtain an addendum opinion from a physician (M.D.) regarding the Veteran’s claimed allergy disability. The examiner must opine on the following in regard to periods of service from October 1988 to November 1991 and December 2007 to June 2008 (deployed to Iraq): (a.) whether it is at least as likely as not related to an in-service injury, event, or disease, to include dust and burn pit exposure in Iraq and/or any other medical symptoms endorsed during service. 11. Schedule the Veteran for an examination of the current severity of her right ankle disability. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to a right ankle disability alone and discuss the effect of the Veteran’s right ankle on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 12. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of her service-connected chronic bronchitis. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Connally, Counsel