Citation Nr: 1828641 Decision Date: 05/11/18 Archive Date: 05/18/18 DOCKET NO. 17-46 597 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for variously diagnosed gastrointestinal disabilities, to include hiatal hernia, colon polyps, gastroesophageal reflux disease (GERD), and stomach ulcers to include as secondary to service-connected IBS; or secondary to radiation exposure; or pursuant to the provisions of 38 U.S.C. § 1151 for private treatment from December 2016 to March 2017; or due to an undiagnosed illness or medically unexplained chronic multi-symptom illness resulting from service in Southwest Asia during the Persian Gulf War. 2. Entitlement to service connection for variously diagnosed gynecological disorders to include menorrhagia, bilateral salpingo oophorectomy, residuals of total hysterectomy, uterine fibroid tumors, menstrual disorder, endometriosis, ovarian cysts, female sexual arousal disorder, and precancerous cells to include as secondary to radiation exposure; or pursuant to the provisions of 38 U.S.C. § 1151 for private treatment from December 2016 to March 2017; or due to an undiagnosed illness or medically unexplained chronic multi-symptom illness resulting from service in Southwest Asia during the Persian Gulf War. 3. Entitlement to service connection for migraine headaches to include as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness resulting from service in Southwest Asia during the Persian Gulf War. 4. Entitlement to service connection for variously diagnosed psychiatric disorders to include schizophrenia, hallucinations, insomnia, and depression, to include as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness resulting from service in Southwest Asia during the Persian Gulf War. 5. Entitlement to temporary total evaluation due to hospitalization over 21 days. 6. Entitlement to a temporary total convalescence rating following surgery. 7. Entitlement to an initial rating in excess of 30 percent for irritable bowel syndrome (IBS). 8. Entitlement to a total rating based on individual unemployability due to service connected disabilities (TDIU). REPRESENTATION Appellant represented by: Virginia Department of Veterans Services ATTORNEY FOR THE BOARD A. D. Jackson, Counsel INTRODUCTION The Veteran had active service from May 1993 to June 2001. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). This case has a complicated procedural history. In September 2016 the RO granted service connection for IBS, assigning a 30 percent evaluation effective in November 2014. The RO also denied in pertinent part, service connection for headaches, ulcers, psychiatric disorders and uterine fibroid tumors, for which the Veteran filed a notice of disagreement (NOD) later that month. Thereafter, the Veteran raised various issues to include contending that her symptoms were part of a multi-symptom undiagnosed illness (see October 2016 statement); entitlement to a higher rating for IBS; entitlement to service connection for residuals of hysterectomy; entitlement to temporary total evaluations based on hospitalization; entitlement to temporary total evaluations based on convalescence; entitlement to TDIU; and entitlement to compensation pursuant to the provisions of 38 U.S.C. § 1151 (see March 2017 statements); and entitlement to service connection for gastrointestinal disorders secondary to IBS and endometriosis (see May 2017 statements). A rating action in May 2017, in pertinent part, denied service connection for hiatal hernia, gastrointestinal disorders, residuals of hysterectomy; entitlement to temporary total evaluation based on hospitalization; entitlement to temporary total evaluation based on convalescence; and entitlement to TDIU. The RO issued a statement of the cases(SOC) in June 2017 that listed the issues of entitlement to a higher rating for IBS; entitlement to service connection for migraine headaches, gastrointestinal disorders to include stomach ulcers, and hiatal hernia; and variously diagnosed gynecological disorders to include uterine fibroid tumors, endometriosis, and residuals of hysterectomy (secondary to uterine fibroid tumor); entitlement to temporary total evaluation based on hospitalization; entitlement to temporary total evaluation based on convalescence; and entitlement to TDIU. In August 2017, the Veteran submitted a substantive appeal, VA Form 9, that only referred to the denials of service connection for a psychiatric disorder, endometriosis and residuals of hysterectomy. Although the Veteran only referred to three claims in the VA Form 9, she also submitted an application for TDIU benefits the next month, in September 2017, in which she continued to refer to her claims for service connection for gastrointestinal problems, gynecological disorders, and temporary total evaluations. This can be construed as a substantive appeal. The RO issued supplemental statements of the case (SSOC) in December 2017 that addressed the issues of service connection for variously diagnosed psychiatric disorder, stomach ulcers, variously diagnosed gynecological disorders, gastrointestinal disorders, TDIU, and temporary total evaluations. The RO has certified these claims as well as the claim for higher rating for IBS to the Board for review. Also see Percy v. Shinseki, 23 Vet App. 37 (2009); Gonzalez-Morales v. Principi, 16 Vet. App. 556 (2003) (per curiam order). Considering the Veteran's lack of representation for the most part of her appeal, the Board has liberally viewed her contentions and various theories of entitlement, she has purported over the years. The Board has listed the issues on the title page in the most favorable light to the Veteran. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that when a claimant makes a claim, she is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2). As explained below, the claim of service connection for endometriosis is granted and the remaining issues will be remanded to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT It is as least as likely as not that the Veteran's currently diagnosed endometriosis is related to military service. CONCLUSION OF LAW The criteria for entitlement to service connection for endometriosis have been met. 38 U.S.C. §§ 1110, 1137 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION VA has specified duties to notify and assist a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. Through various correspondences, remands, and examination the VA has fulfilled these duties. Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303(a). In regard to element (1), current disability, December 2016 private examination indicates diagnoses of endometriosis. In regard to element (2), in-service incurrence, the Veteran received medical treatment for endometriosis during service. See July 1999 clinical notes. In regard to element (3), causal relationship, the record contains a December 2017 VA medical opinion which supports the claim. As the record contains credible medical opinion weighing in favor of the Veteran's claim, the Board finds that the evidence regarding the third element, causal relationship, is satisfied. As all three elements have been satisfied, the Board finds that service connection for endometriosis is warranted. ORDER Service connection for endometriosis is granted. REMAND In regard to the claim for a higher rating for IBS, VA examination was conducted in November 2017, the RO has not issued a SSOC. In light of the Veteran's claims, VA examinations and opinions are needed. The claims of entitlement to TDIU and temporary total evaluations are inextricably intertwined with the service connection and higher rating claims. The outcome of her appeal on these issues has an immediate effect on her claims for TDIU and temporary total evaluations. Consideration of these claims must be deferred pending resolution of those claims. Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Make arrangements to obtain the Veteran's VA treatment records from December 2017 to the present. 2. Schedule the Veteran for appropriate VA examinations to obtain evidence as to the etiology of the claimed disabilities. The examiners should obtain a complete history from the Veteran. The Veteran contends that her disabilities are the result of her service, to include her exposure to ionizing radiation and biochemical hazards in service. Psychiatric Disabilities a. After reviewing the record, the examiner should identify all current psychiatric disorders. The examiner should then provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that each identified acquired psychiatric disorder manifested in or is otherwise related to the Veteran's period of service to include secondary to her service connected disabilities or due to an undiagnosed illness or medically unexplained chronic multi-symptom illness resulting from her service in Southwest Asia during the Persian Gulf War as bioenvironmental engineer. b. To the best of his/her ability, the examiner must reconcile all previous psychiatric diagnoses documented in the records and offer an opinion as to the onset date of the Veteran's psychiatric condition(s). The examiner should take into consideration and comment on the conclusions of the Veteran's private physician received in November 2016 and in October 2017. c. Gastrointestinal Disorders The examiner must identify all disorders of the gastrointestinal system found to be present including colon polyps, hiatal hernia, GERD, and stomach ulcers. The examiner should provide an opinion as to whether it is at least as likely as not (50% or greater probability) any current gastrointestinal disorder had its clinical onset during active service or is related to any in-service disease, event, or injury. This includes exposure to radiation, or secondary to service connected IBS, or due to an undiagnosed illness or medically unexplained chronic multi-symptom illness resulting from her service in Southwest Asia during the Persian Gulf War as bioenvironmental engineer. The examiner should comment on the Veteran's inservice training as bioenvironmental engineer along with her exposure to all hazardous material. d. Gynecological Disorders The examiner must identify all gynecological disorders found to be present. The examiner should provide an opinion as to whether it is at least as likely as not (50% or greater probability) any current gynecological disorder (including resulting hysterectomy) had its clinical onset during active service or is related to any in-service disease, event, or injury. This includes exposure to radiation or secondary to service connected IBS, or secondary to service connected endometriosis, or due to an undiagnosed illness or medically unexplained chronic multi-symptom illness resulting from her service in Southwest Asia during the Persian Gulf War as bioenvironmental engineer. The examiner should comment on the Veteran's inservice training as bioenvironmental engineer along with her exposure to all hazardous material. e. Migraine Headaches The examiner should provide an opinion as to whether it is at least as likely as not (50% or greater probability) migraine headaches had its clinical onset during active service or is related to any in-service disease, event, or injury. This includes exposure to radiation and/or due to an undiagnosed illness or medically unexplained chronic multi-symptom illness resulting from her service in Southwest Asia during the Persian Gulf War as bioenvironmental engineer. The examiner should consider and comment on the Veteran's inservice treatment headaches in November 1993 and January 1996. A complete rationale must accompany all opinions rendered. 3. If, and only if, a VA examiner determines that any of the Veteran's claimed disabilities are a "radiogenic disease" in accordance with 38 C.F.R. § 3.311 (a)(2)(iii), undertake the necessary development required for such claims. 4. Finally, readjudicate the claims on appeal based upon all additional evidence received. 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). ______________________________________________ M. Tenner Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs