Citation Nr: 18160300 Decision Date: 12/28/18 Archive Date: 12/26/18 DOCKET NO. 15-29 181 DATE: December 28, 2018 ORDER Entitlement to service connection for cervical spine disorder is dismissed. Entitlement to service connection for a liver disorder is dismissed. Entitlement to service connection for Crohn's disease is dismissed. Entitlement to an initial evaluation in excess of 10 percent for eczema is dismissed. REMANDED Entitlement to service connection for a thyroid disorder is remanded. Entitlement to an initial evaluation in excess of 30 percent for sinusitis is remanded. Entitlement to an initial evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to an evaluation in excess of 10 percent for hypertension with transient dizziness is remanded. Entitlement to a total disability evaluation based upon individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDING OF FACT During the June 2017 Board hearing, prior to the promulgation of a decision, the Veteran indicated that he wanted to withdraw his appeal for the issues of entitlement to an increased evaluation for his service-connected eczema and to service connection for a liver disorder, cervical spine disorder, and Crohn’s disease. CONCLUSION OF LAW The criteria for withdrawal of an appeal have been met for the issues of entitlement to an increased evaluation for service-connected eczema and to service connection for a liver disorder, cervical spine disorder, and Crohn’s disease. 38 U.S.C. § 7105 (b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1983 to September 1991. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from June 2015 and September 2016 rating decisions from the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in June 2017. A transcript is of record. The Board notes that additional evidence has been received since the last adjudication of some of the claims. The evidence was submitted by the Veteran and accompanied with a waiver. Law and Analysis The Board may dismiss any appeal which fails to allege a particular error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. Withdrawal of an appeal is deemed a withdrawal of the Notice of Disagreement and, if filed, the Substantive Appeal, as to all issues to which the withdrawal applies. 38 C.F.R. § 20.204(c). During the June 2017 Board hearing, the Veteran and his representative withdrew his appeal for the issues of entitlement to an increased evaluation for his service-connected eczema and to service connection for a liver disorder, cervical spine disorder, and Crohn’s disease. Thus, there remains no allegation of errors of fact or law for appellate consideration concerning those claims. Accordingly, the Board does not have jurisdiction to review the appeal of the issues, and they are dismissed. REASONS FOR REMAND Thyroid Disorder During the June 2017 Board hearing, the Veteran testified that he received treatment from a medical facility in West Palm Beach, Florida, in 2013 or 2015 for his thyroid disorder. However, the claims file does not contain these records. Further, there is no indication that the AOJ has attempted to obtain these records. Thus, the AOJ should request an authorization from the Veteran and attempt to secure the records. Additionally, the Veteran was afforded to VA examination in connection with his claim in August 2011. During the examination, the Veteran was found to have a thyroid condition that was diagnosed as Hashimoto’s disease in 1994. The examiner stated that he was unable to provide an opinion without resorting to mere speculation because the Veteran’s service treatment records did not note a thyroid condition, and there was no current medical literature to support a nexus between a thyroid condition and environmental exposures in Southwest Asia. In a May 2015 VA examination report, the examiner noted that the Veteran had hypothyroidism and a malignant neoplasm and had undergone a thyroidectomy. The Veteran reported that he had not undergoing radioactive iodine treatment, and he was not found to have any other thyroid or parathyroid condition. The examiner noted that the Veteran was not diagnosed with thyroid cancer until 20 years after his military service and opined that it is less likely than not the Veteran’s current thyroid disorder is related to his military service. The Board finds the opinion is inadequate as it is based on non-factual information related to the year the Veteran was diagnosed with a thyroid disorder. However, the examiner did not address the report that the Veteran was first diagnosed with a thyroid condition in 1994. Moreover, the examiner did not address the Veteran’s lay assertions or potential health impact of inhalation of dust, smoke, and burning chemicals and fuel and a possible relation to his thyroid disorder. Therefore, the claim must be remanded for another VA examination and opinion to determine the nature and etiology of any thyroid disorder. Sinusitis The Veteran was afforded a VA examination in May 2015 in connection with his sinusitis claim. At that time, the examiner noted the Veteran experienced chronic sinusitis. However, during the June 2017 hearing, the Veteran described various symptoms, including headaches, sinus pressure, and a runny nose. Additionally, the Veteran’s treatment records reveal that he had sinus surgery in April 2016 and currently uses steroid nasal spray and an allergy pill to control his sinusitis. Thus, the evidence suggests the Veteran’s condition may have worsened since the May 2015 VA examination. For these reasons, the Board finds that an additional VA examination is needed to ascertain the current severity and manifestations of the Veteran’s service-connected sinusitis. PTSD The Veteran was most recently afforded a VA examination in June 2016 in connection with his PTSD claim. He later submitted private evaluations dated in August 2016 and July 2017. However, his June 2017 hearing testimony suggests that his disorder has worsened since his last examination and that all of his symptoms were not noted in the private evaluations. During the June 2016 VA examination, the Veteran was noted to have symptoms that resulted in an occupational and social impairment with an occasional decrease in work efficiency. His symptoms included panic attacks, chronic sleep impairment, and difficulty in relationships and adapting to stressful circumstances. During the hearing, the Veteran testified that he experiences panic attacks three to five times per week, depressed mood, isolation, suicidal and homicidal thoughts, violent and verbal altercations, short-term memory loss, nightmares, and possible obsessional rituals. Therefore, the AOJ should provide the Veteran with another VA examination to ascertain the current severity and manifestations of his service-connected PTSD. Hypertension The Board was most recently afforded a VA examination in connection with his hypertension claim in June 2016. At that time, the Veteran was noted to take continuous medication for his condition, and he had diastolic pressure predominantly 100 or more. However, his June 2017 Board hearing testimony suggests that the disorder may have worsened since the last examination. For example, the Veteran indicated that he had been hospitalized for chest pains, takes a lot of medication, has massive chest pain, and had recent found out that he had blockages in his kidneys resulting in urination every hour. Therefore, on remand, the AOJ should provide the Veteran with another VA examination to ascertain the current severity and manifestations of his service-connected hypertension. The Board also notes the Veteran stated that he was treated at the Marinette VA and Bay Area Medical Hospital in May 2017 related to his hypertension. However, those records have not been obtained and associated with the file. On remand, the AOJ should attempt to get authorization from the Veteran and obtain the records. TDIU The Veteran is currently service-connected for sinusitis, PTSD, irritable bowel syndrome, residuals of dislocation of the left shoulder, hypertension with transient dizziness, sinus arrhythmia, eczema, and a fascial defect of the left lower leg. His combined evaluation is 80 percent. However, there is no medical opinion addressing the combined effects of his service-connected disabilities. Therefore, the Board finds an examination is needed prior to adjudication of the issue of entitlement to TDIU. The Board also notes that the issue of entitlement to TDIU is inextricably intertwined with the other issues being remanded. The matters are REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should request the Veteran provide the names and addresses of all healthcare providers who have provided treatment for his hypertension, PTSD, sinusitis, and thyroid disorder. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate the records with the claims file, to include any records related to the Veteran’s thyroid disorder noted during the June 2017 hearing and May 2017 treatment records from Marinette VA and Bay Area Medical Hospital. The AOJ should also secure any outstanding VA medical records. 2. After any additional records are associated with the claims file, the Veteran should be afforded a VA examination to determine the nature and etiology of any thyroid disorder. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should provide an opinion on whether the Veteran’s thyroid disorder is at least as likely as not related to his military service, to include exposure to environmental or chemical hazards while he was serving in the Persian Gulf. In rendering the requested opinion, the examiner must consider the Veteran’s contentions and earlier diagnosis of a thyroid disorder shortly after discharge from service. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. After obtaining any outstanding records, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected sinusitis. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the Veteran’s sinusitis. In particular, he or she should state the number of incapacitating episodes that the Veteran experiences per year requiring prolonged (lasting four to six weeks) antibiotic treatment and how many non-incapacitating episodes per year of sinusitis the Veteran experiences, which are characterized by headaches, pain, and purulent discharge or crusting. The examiner should also indicate whether there has been radical surgery with chronic osteomyelitis or near constant sinusitis characterized by headaches, pain, and tenderness of affected sinus and purulent discharge or crusting after repeated surgeries. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 4. After obtaining any outstanding records, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected PTSD. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including any treatment records and assertions. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the Veteran’s disability under the General Rating Formula. The findings of the examiner should address the level of social and occupational impairment attributable to the Veteran’s PTSD. A clear rationale for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability is viewed in relation to its history”, copies of all pertinent records in the Veteran’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 5. After obtaining any outstanding records, the Veteran should be afforded a VA examination to ascertain the severity and manifestations of his service-connected hypertension. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the left disability under the rating criteria. In particular, the examiner should provide blood pressure readings and indicate whether the Veteran requires continuous medication for control The examiner should also identify any other symptoms or manifestations of the service-connected disability. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history[,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 6. After obtaining any outstanding records, the AOJ should schedule the Veteran for a VA examination to determine the combined effects of his service-connected disabilities and any resulting impairment. The examiner should address how the Veteran’s service-connected disabilities alone result in functional impairment and comment on the Veteran’s ability to function in an occupational environment. If possible, he or she should also indicate if there is any form of employment that the Veteran could perform, and if so, what type. A written copy of the report should be associated with the electronic claims folder. 7. The AOJ should conduct any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K.M. Walker, Associate Counsel