Citation Nr: 1821202 Decision Date: 04/11/18 Archive Date: 04/19/18 DOCKET NO. 14-27 071 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for left shoulder disability. 2. Entitlement to service connection for left eye stye. 3. Entitlement to service connection for refractive error, to include as secondary to stye. 4. Entitlement to service connection for gastroesophageal reflux disease (GERD claimed as acid reflux). 5. Entitlement to service connection for erectile dysfunction (claimed as sexual dysfunction). ATTORNEY FOR THE BOARD K. Foster, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1985 to November 1985 and from October 2008 and October 2009, with additional periods of active military service. This matter comes before the Board of Veterans' Appeals (Board or BVA) on appeal from a January 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. The Board notes that the Veteran left blank the portion of his July 2014 VA Form 9 where he could request a hearing. Subsequently, in July 2014, the RO sent the Veteran correspondence giving him another opportunity to request a hearing. It does not appear that the Veteran responded to this letter. Accordingly, the Board determines that the Veteran has waived his right to hearing and will proceed with adjudication. In February 2013 correspondence, the Veteran indicated that he believes his claimed refractive error is the result of dust storms and the resulting styes caused by said storms. Although the Veteran is not presently service connected for eye stye(s), the Board has noted this theory of potential entitlement based on secondary service connection on the title page. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran, if further action is required. REMAND After a careful review of the evidence of record, the Board finds that additional development is needed prior to adjudicating the claim. The record reflects that the Veteran served with the Army National Guard from October 1984 to February 2012, with periods of non-military, civilian break between June 15, 1993 to January 20, 1995 and January 21, 1999 to February 19, 2003. Active military service dates have been confirmed for periods between July 1985 to November 1985 and from October 2008 to October 2009. However, a review of the record shows that there may be additional periods of active military service that have not been confirmed or identified. Therefore, the Board will remand to confirm the periods for which the Veteran had active military service. In addition, the Board will remand to obtain any missing service treatment records that have not been associated with the claim file, as it appears that some treatment records may be missing. For example, the Veteran's DD 214 indicates that the Veteran had service in Iraq from November 30, 2008 to October 1, 2009, and there is a pre-deployment health assessment from October 2008 included in the Veteran's service treatment records. However, there is no post-deployment health assessment. By contrast, there is a post-deployment health assessment for September 2005 concerning the Veteran's deployment to assist in Hurricane Katrina relief efforts, however, no pre-deployment assessment. Further, a March 2012 service treatment record states that the Veteran has a left shoulder injury that "occurred during tour in Iraq . . . He also had a temporary profile." The record currently does not show a temporary profile other than one from March 2012 to June 2012, which postdates the Veteran's service in Iraq. Therefore, the Board will remand to permit a search for potential documentation of a temporary profile while the Veteran served in Iraq. Further, in February 2013 correspondence, the Veteran states that he was treated for styes in his eye while in Iraq, however, there are no service treatment records in the file indicating such treatment. The Board does note that service treatment records from April and May 2009 indicate that the Veteran's history of medical problems includes refractive error and stye. Finally, the Board notes that several of the Veteran's service treatment records have been improperly scanned with sections cut off, folded, or missing. The Board will remand to obtain any outstanding records, as well as complete scans of all available images. Furthermore, the Board finds that the Veteran should be scheduled for new VA examinations. The Veteran was afforded a VA examination in January 2013 concerning his claimed left shoulder disability. The examiner diagnosed the Veteran with DJD of the left shoulder and tendinosis of the left supraspinatus, however, provided no opinion regarding whether the identified disabilities were potentially connected to the Veteran's service. The Board notes that the Veteran has offered several theories regarding the etiology of his left should disability. For example, in February 2013 correspondence, the Veteran states that his left shoulder was injured in Iraq within two weeks of leaving country, specifically, during a softball game. He states that it worsened after he returned to the United States and that is when he reported it to the VA. In a September 2010 VA treatment record, the Veteran complained of his left shoulder popping and cracking and that he is losing range of motion above his head level. The Veteran contended that these symptoms started a couple of months ago when he was at drill when he was taking a huge pan out of the oven and twisted to put it on a warmer. In addition, a service treatment record from March 2012 states that the Veteran's left shoulder injury is the result of body armor. The Board will remand to afford the Veteran a new examination, as well as to obtain an opinion regarding the etiology of his claimed disability, particularly regarding clarification of the triggering event in service, if any. The Board notes that the Veteran was ordered to active duty for special work (ADSW) for the period from August 14, 2006 to June 30, 2007, and at least part of his service was in Arizona. In February 2013 correspondence, the Veteran stated that he has reoccurring styes that are the result of active duty in Phoenix when he was in dust storms. He also points to dust storms experienced while serving in Iraq and states that he was treated there as well. A treatment record from August 29, 2006 notes that the Veteran has swelling of the left lower lid for two days. However, an opinion provided by the attending physician/patient administrator indicates that the injury was not incurred in the line of duty and is not likely to result in a claim against the government for future medical care. However, the Board finds this to be an insufficient opinion for the purposes of determining service connection. First, it does not address the etiology of the eye condition or state whether if it pre-existed service, if it was aggravated therein. In addition, it does not address the Veteran's contention that the dust in Arizona caused his eye maladies. The Board will remand to afford the Veteran a VA examination regarding his claimed eye disabilities and to obtain an opinion that addresses their etiologies. Accordingly, the appeal is REMANDED for the following action: 1. The AOJ should contact the appropriate agencies to confirm all periods of active duty service. All efforts to confirm the active duty periods should be clearly documented in the claim file. In addition, the AOJ should attempt to obtain any missing service treatment records that have not been associated with the claim file. Specifically, the Board points to pre- and post-deployment evaluations and service treatment records from the Veteran's deployment to Iraq, including record of a temporary profile for the Veteran's left shoulder, as well as treatment for refractive error and styes. All efforts to obtain such records should be clearly noted in the claim file. In addition, the Veteran's service treatment records should be reviewed in order to ensure that complete scans of all documents are included in the claim file and improperly scanned documents (i.e. incomplete documents with sections cut off, folded, or missing) are corrected. If this is not possible, it should be clearly noted and explained in the claim file. Finally, after securing any necessary consent forms from the Veteran, the AOJ should obtain any outstanding treatment records, to include any VA and/or private treatment records, pertaining to the issues on appeal. All efforts to obtain such records should be clearly noted in the claim file. 2. Upon completion of the above, schedule the Veteran for the following examinations. Examiners should be provided a copy of the claim file and review of the claim file should be noted in any subsequent report. (a) Schedule the Veteran for a VA examination to address the etiology of his left shoulder disability. The examiner should note any diagnoses for the left shoulder and for each diagnosis provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that it was caused by the Veteran's active duty service or, if preexisting service, was aggravated therein. (b) In addition, schedule the Veteran for an examination regarding his claimed eye disabilities. The examiner should note any diagnoses for the eye(s) and for each diagnosis provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that it was caused by the Veteran's active duty service or, if preexisting service, was aggravated therein. In addition, the examiner should provide an opinion as to whether it is more likely than not (i.e., a 50 percent or greater probability) that the Veteran's refractive error is proximately due to, or the result of, or aggravated (permanently worsened) beyond normal progression by the Veteran's stye(s). (c) If, based on information obtained in the first directive, additional examinations are determined necessary to address the other claimed disabilities on appeal, the Veteran should be scheduled for those as well. A full rationale for any opinion(s) rendered must be provided. If upon completion of the above action the issue is denied, the case should be returned to the Board after compliance with appellate procedures. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This appeal must be afforded expeditious treatment. The law requires that all issues that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). _________________________________________________ E. I. VELEZ Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).