Citation Nr: 20020009
Decision Date: 03/18/20	Archive Date: 03/18/20

DOCKET NO. 18-43 524
DATE: March 18, 2020

REMANDED

Entitlement to service connection for systemic autoimmune disease and residuals is remanded.

REASONS FOR REMAND

The Veteran served on active duty in the United States Army from February 2002 to September 2004.  This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). 

The Veteran asserts that his claimed systemic autoimmune disease is related to service.  Review of the Veteran’s service treatment records (STRs) reflect a diagnosis of erythema multiforme, as well as symptoms of joint pain and skin rashes.  The Veteran’s post-service VA treatment records show diagnoses of Raynaud’s phenomenon and lupus.  To date, the Veteran has not been afforded a VA examination to determine the nature and etiology of his claimed systemic autoimmune disease.  VA’s duty to assist includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim.  McLendon v. Nicholson, 20 Vet. App. 79 (2006).

The matter is REMANDED for the following action:

1. With any necessary identification of sources and authorization by the Veteran, request all VA and private treatment records for the Veteran not already associated with the file.  Copies of any outstanding VA and private treatment records should be added to the Veteran's electronic claims file.

2. Thereafter, schedule the Veteran for a VA examination by an examiner with appropriate expertise to determine the nature and etiology of any diagnosed systemic autoimmune disease.  The Veteran’s electronic claims file must be accessible for review by the VA examination in conjunction with the examination.  A complete history from the Veteran should be obtained and recorded.  All testing deemed necessary by the examiner should be performed and the results reported in detail.  A detailed rationale for all opinions should be provided.

Following the review of the claims file and examination of the Veteran, the examiner is then requested to respond to the following:

Is it at least as likely as not (a 50 percent probability or greater) that any diagnosed systemic autoimmune disease had its onset in service or is otherwise directly related to service?

In rendering the requested opinions, the examiner should consider: (1) the Veteran’s STRs, which show a diagnosis of erythema multiforme, as well reports of joint pain and skin rashes; and (2) the Veteran’s post-service VA treatment records which show diagnoses of Raynaud’s phenomenon and lupus.

3. After completing all indicated development, the Agency of Original Jurisdiction should readjudicate the Veteran’s claim.  If the benefit sought on appeal remains denied, the Veteran should be furnished with a supplemental statement of the case, given the opportunity to respond, and the case should thereafter be returned to the Board for further appellate review, if warranted.

 

 

KELLI A. KORDICH

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	D. Houle, Associate 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.