Citation Nr: 20003877 Decision Date: 01/16/20 Archive Date: 01/15/20 DOCKET NO. 16-10 086 DATE: January 16, 2020 REMANDED Entitlement to service connection for a left eye disability is remanded. Entitlement to service connection for a respiratory disorder is remanded. Entitlement to a disability rating greater than 30 percent for migraine headaches is remanded. Entitlement to a disability rating greater than 30 percent for anxiety disorder, not otherwise specified (NOS) with insomnia, is remanded. Entitlement to a disability rating greater than 10 percent for gastroesophageal reflux disease (GERD) is remanded. Entitlement to a disability rating greater than 10 percent for left knee medial collateral ligament strain is remanded. REASONS FOR REMAND The Veteran served on active duty from July 2008 to July 2013. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a February 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran also presented testimony before RO personnel in April 2016. A transcript of the hearing is associated with the record. In July 2019, the Veteran testified at a videoconference hearing held at the RO before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the record. REASONS FOR REMAND Left Eye With respect to the Veteran’s claim of entitlement to service connection for a left eye disability, the Veteran contends that he has a left eye disability that is related to his service, to include an injury when he fell from a helicopter. The Board notes that the Veteran’s service treatment records do not document the reported in-service injury when he fell from a helicopter. However, the Board notes that the Veteran was an avionics Marine in service and also had service in Afghanistan. As such, the Board finds the Veteran credible with regard to the reported in-service injury. The Board notes that Dr. J.E. opined in a May 2019 private treatment report that the Veteran has diplopia that is due to the in-service injury when the Veteran fell from a helicopter. In light of the foregoing, the Board finds that an opinion should be obtained on remand which addresses such. Respiratory With regard to the Veteran’s claim of service connection for a respiratory disorder, the Veteran contends that he has a respiratory disorder that is related to service, to include exposure to jet exhaust fumes as well as sandstorms and burn pits during service in Afghanistan. See, e.g., the July 2019 Board hearing transcript, page 31. The Board notes that the Veteran’s service treatment records are absent treatment for a respiratory disorder. However, the Board notes the Veteran’s service as avionics Marine and service in Afghanistan which is consistent with exposure to jet fumes, sandstorms, and burn pits. The Board notes that Dr. J.E. opined in a May 2019 private treatment report that the Veteran has asthma and bronchiectasis that is due to the in-service exposure to jet fumes, sandstorms, and burn pits. In light of the foregoing, the Board finds that an opinion should be obtained on remand which addresses such. Migraines The Veteran most recently had a VA examination in connection with his claim in January 2015. During the July 2019 hearing before the Board, the Veteran’s testimony indicated that his symptoms may have worsened since his last VA examination. Consequently, a remand for a current examination is necessary. Anxiety With respect to the Veteran’s claim of entitlement to an increased disability rating for anxiety disorder, the Veteran’s most recent VA examination for this disability was in January 2015. At that time, the Veteran reported a positive relationship with his wife and children. Further, the only mental health symptoms documented by the VA examiner were depressed mood, anxiety, and chronic sleep impairment. Pertinently, during a RO hearing in April 2016, the Veteran reported that his anxiety disorder worsened since the VA examination. He thereafter submitted a VA Disability Benefits Questionnaire (DBQ) completed by H.K., Ph.D. Dr. H.K. opined that the Veteran’s mental health impairment was manifested by occupational and social impairment with reduced reliability and productivity which is consistent with a 50 percent disability rating under 38 C.F.R. § 4.125, Diagnostic Code 9413. The Veteran subsequently submitted a private treatment evaluation dated May 2019 by Dr. J.E. who documented the Veteran’s report of suicidal ideation which is a criterion consistent with a 70 percent rating under Diagnostic Code 9413. As the evidence therefore indicates a worsening of the Veteran’s anxiety disorder symptoms and the current severity of such is unclear, the Board finds that he should be provided a VA examination for this disability on remand. See Snuffer v. Gober, 10 Vet. App. 400 (1997) (a veteran is entitled to a new VA examination where there is evidence that the condition has worsened since the last examination). GERD With regard to the Veteran’s claim of entitlement to an increased disability rating for GERD, the Veteran was most recently provided a VA examination for this disability in January 2015. At that time, the examiner documented symptoms of dysphagia, pyrosis, reflux, substernal and shoulder pain, sleep disturbance, nausea, and vomiting. Pertinently, during the July 2019 Board hearing, the Veteran indicated a worsening of these symptoms in that he experiences greater frequency of epigastric distress and general impairment of health. See the July 2019 Board hearing transcript, pgs. 22-24. In light of the foregoing, the Board finds that the Veteran should be provided a VA examination to determine the current level of severity of his GERD. Left Knee Finally, with respect to the Veteran’s claim of entitlement to an increased disability rating for left knee medial collateral ligament strain, the Veteran was most recently provided a VA examination for this disability in January 2015. During the April 2016 RO hearing, the Veteran reported that his left knee disability had since worsened. Notably, he submitted a private treatment evaluation dated May 2019 from Dr. J.E. which indicated decreased range of left knee motion as well as instability. As such, the Board finds that the Veteran should be provided a VA examination to determine the current level of severity of his left knee medial collateral ligament strain. The matters are REMANDED for the following action: 1. After securing any necessary release, obtain any outstanding VA and/or private treatment records pertaining to the claims on appeal. 2. Thereafter, arrange for the Veteran to undergo a VA examination by an appropriate examiner to determine the etiology of any left eye disability. The claims file must be made available to the examiner. The examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran has a left eye disability to include diplopia that is related to his service, to include his injury from falling from a helicopter. The underlying reasons for all opinions expressed must be provided. The examiner is asked to consider the May 2019 opinion by Dr. J. Ellis. 3. After the development in #1 has been completed, arrange for the Veteran to undergo a VA examination by an appropriate examiner to determine the etiology of any respiratory disorder. The entire claims file must be made available to the examiner. The examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran has a respiratory disorder to include asthma and bronchiectasis that is related to his service, to include exposure to jet exhaust fumes as well as sandstorms and burn pits. The underlying reasons for all opinions expressed must be provided. The examiner is asked to consider the May 2019 opinion by Dr. J. Ellis. 4. After the development in #1 has been completed, provide the Veteran with an appropriate VA examination to determine the current symptoms and severity of his service-connected migraines. The claims folder must be made available to the examiner. The current severity and manifestations on his employment should be addressed. 5. After the development in #1 has been completed, provide the Veteran with an appropriate VA examination to determine the current symptoms and severity of his service-connected anxiety disorder. The claims folder must be made available to the examiner. All tests and studies deemed necessary by the examiner should be performed. In discussing the relevant clinical findings, the examiner should specifically note the Veteran’s current complaints, symptoms, any interference with daily and/or occupational activities, and the level of disability. 6. After the development in #1 has been completed, provide the Veteran with an appropriate VA examination to determine the current symptoms and severity of his service-connected GERD. The claims folder must be made available to the examiner. All tests and studies deemed necessary by the examiner should be performed. In discussing the relevant clinical findings, the examiner should specifically note the Veteran’s current complaints, symptoms, any interference with daily and/or occupational activities, and the level of disability. 7. After the development in #1 has been completed, schedule the Veteran for appropriate VA examination to assess the manifestations of the Veteran’s service-connected left knee medial collateral ligament strain. The claims folder must be reviewed in conjunction with the examination. All testing deemed necessary must be conducted and results reported in detail. Regarding the orthopedic manifestations, the examiner is asked to indicate the point during range of motion testing that motion is limited by pain. The examiner should describe in detail the presence or absence and the extent of any functional loss due to weakened movement, excess fatigability, incoordination, or pain on use, and should state whether any pain claimed by the Veteran is supported by adequate pathology, e.g., muscle spasm, and is evidenced by his visible behavior, e.g., facial expression or wincing, on pressure or manipulation. The examiner should express an opinion as to whether pain or other manifestations occurring during flare-ups or with repeated use could significantly limit functional ability of the affected part. The examiner should portray the degree of any additional range of motion loss due to pain on use or during flare-ups. The examiner should test the range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing for the right and left knees. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Kamal, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.