Citation Nr: 20076167 Decision Date: 12/01/20 Archive Date: 12/01/20 DOCKET NO. 13-01 356 DATE: December 1, 2020 REMANDED Service connection for myositis, to include as secondary to service-connected hypertension and/or posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from May 2001 to November 2008. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2010 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2016, the Board remanded this claim. The Veteran testified at a May 2016 Board hearing before a Veterans Law Judge (VLJ) in Washington, D.C. A transcript of the hearing is of record. The Veteran was notified in February 2017 that the VLJ who conducted the May 2016 Board hearing was no longer employed by the Board and she was provided the opportunity to request another Board hearing. In correspondence received in March 2017, the Veteran indicated that she did not wish to appear at another Board hearing. These matters came before the Board in April 2018 and were once again remanded for further development. Service connection for myositis, to include as secondary to service-connected hypertension and/or PTSD is remanded. While the Board sincerely regrets the additional delay, further development of the record is necessary to comply with VA’s duty to assist the Veteran in the development of facts pertinent to his claims. Where the remand orders of the Board are not fully complied with, the Board errs as a matter of law when it fails to ensure compliance. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The May 2018 Board remand instructed the examiner to review the Veteran’s service treatment records (STRs) dated from September 2008 to November 2008 which included under the Veteran’s problem list “myalgia and myositis” and post-service treatment records (received in September 2009 from the Langley Air Force Base Medical Center) dated from December 2008 to May 2009 that included the same notations. The Veteran was afforded an October 2019 VA examination during which the conducting physician was unable to confirm a current diagnosis of myositis with current available records and the Veteran’s reported diagnosis is subjective only. The physician indicated that the only medical records they reviewed were February 2010 X-ray records, 2008 MRI reports, a July 2013 C.T. scan and a 2014 medical record. When VA obtains an examination or opinion, that examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Review of the record, as summarized above, indicates that the VA opinion of record is not adequate because it does not sufficiently address the pertinent evidence of record. Additionally, an October 2018 physician note indicates that the Veteran has a current diagnosis of polymyositis. Accordingly, a remand is necessary to explain this discrepancy. The matters are REMANDED for the following action: 1. Please note that, by law, ALL remanded claims must be processed expeditiously. 2. Obtain all outstanding VA treatment records. 3. Afford the Veteran a VA examination with respect to her claim for entitlement to service connection for myositis. The medical professional must provide an opinion addressing the following: a. At any point during the Veteran’s active service and afterwards, has she had myositis? The Veteran reports that she has polymyositis that is at times manifested by a rash and is related to sepsis in service. The examiner should conduct any additional laboratory examination(s) deemed necessary. If no further resting is required, the examiner should explain why not. b. Attention is invited to the STRs dated from September 2008 to November 2008 that included under the Veteran’s problem list “myalgia and myositis” and to post-service treatment records (received in September 2009 from the Langley Air Force Base Medical Center) dated from December 2008 to May 2009 that included the same notations. c. Attention is also invited to the Veteran’s statement (in a December 2012 statement and at the May 2016 Board hearing) that October 16, 2008 lab testing results, to include elevated ESR and haptoglobin results, showed muscle damage and provided a bases for a diagnosis of polymyositis. d. Attention is finally invited to the October 2018 physician note indicating that the Veteran has a current diagnosis of polymyositis. 4. If the answer to item “a” is positive (that the Veteran has had myositis), the medical professional is asked to address the following: i. Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that myositis had its onset during active service or is related to any in-service disease, event, or injury. ii. Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that myositis is due to or caused by the Veteran’s PTSD. iii. Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that myositis been aggravated (i.e., increased in severity) by the Veteran’s PTSD. With respect to items “ii” and “iii,” attention is invited to medical treatise information submitted in May 2016 and to the September 2016 VA Mental Disorders Disability Benefits Questionnaire (DBQ) that noted the Veteran’s report that “she noticed an increase in myositis when she is stressed.” 5. If the answer to item “a” is negative (that the Veteran has not had myositis) the medical professional must explain the discrepancy with the previous diagnosis of myositis. Additionally, the examiner is asked to address the following: i. Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran’s reported musculoskeletal pain had its onset during active service or is related to any in-service disease, event, or injury, to include in-service musculoskeletal pain (which was noted in STRs, to include the referenced notations of myalgia). ii. Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran’s reported musculoskeletal pain is due to or caused by the Veteran’s hypertension and/or PTSD. iii. Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran’s reported musculoskeletal pain has been aggravated (i.e., increased in severity) by the Veteran’s hypertension and/or PTSD. For all opinions provided, the examiner must include the underlying reasons for any conclusions reached. [CONTINUED ON NEXT PAGE] 6. After completing the requested actions, readjudicate the claim in light of all pertinent evidence. If the benefit sought remains denied, furnish to the Veteran and her representative a Supplemental Statement of the Case VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Alexander Bahus 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.