Citation Nr: 20021579 Decision Date: 03/26/20 Archive Date: 03/26/20 DOCKET NO. 15-31 185 DATE: March 26, 2020 REMANDED The claim of entitlement to service connection for hemorrhoids is remanded. The claim of entitlement to service connection for tinnitus is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1987 to January 1988 and from February 2003 to May 2004. The Department of Veterans Affairs is grateful for his service. Regrettably, both appealed claims must be remanded for additional development before the Board of Veterans’ Appeals (Board) may adjudicate the claims. 1. The claim of entitlement to service connection for hemorrhoids is remanded. The Veteran contends that he has hemorrhoids which began during his active duty deployment from 2003 to 2004. Service records from the Veteran’s period of active service from 2003 to 2004 do not document hemorrhoids. However, at an April 2004 general examination, it was noted that a rectal examination was not conducted, and in a November 2004 report of medical history the Veteran reported having hemorrhoids from his last deployment. Upon VA examination in January 2015, the Veteran reported that he was constipated while on active duty and this led to his hemorrhoids. He added that symptoms seemed to be worse during the summer, and that he treated the condition with Preparation H as needed. The examiner noted a history of mild to moderate hemorrhoids with occasional bleeding and itching. However, upon examination, no hemorrhoids were observed, with no external hemorrhoids, anal fissures, or other abnormalities. The Veteran also had no history of related surgery. The examiner provided no opinion of etiology of current hemorrhoids because no hemorrhoids were found upon examination. Also of record is an August 2015 medical note by S.C., PA-C, of Gastroenterology Associates of North Florida, informing that the Veteran was first been seen by the gastroenterology practice in April 2015 for rectal bleeding with a reported pattern of intermittent rectal bleeding for over a year. The Veteran had provided a history of onset of difficulties while on active duty from 2003 to 2004 with constipation and straining associated with a low fiber diet and consumption of MRE’s during that service period. The Veteran reported that his symptoms had worsened over time with hemorrhoids that flared up and resulted in rectal bleeding. He added that he had been seen by a primary care physician in 2011 also for rectal bleeding. Progression of the condition led to the Veteran being seen by the gastroenterology practice. A colonoscopy performed by Gastroenterology Associates revealed internal hemorrhoids. The physician’s assistant opined that the Veteran’s history of rectal pain, bleeding, and internal hemorrhoids could be have begun during active duty “if the diet that was provided was not up to par with adequate dietary fiber.” Remand is warranted for a new examination to address hemorrhoids. The VA examination report showed no hemorrhoids on evaluation and thus no etiology opinion was provided. However, private treatment records a few months later show a diagnosis of hemorrhoids. Therefore, on remand, an examination must be provided to reconcile whether the Veteran has hemorrhoids and if so, the etiology of such. Additionally, on remand, records from Gastroenterology Associates of North Florida should be obtained and reviewed, to include any colonoscopy photographs or other documentation of internal hemorrhoids. Records from the primary care physician who treated the Veteran for hemorrhoids in 2011 should also be obtained and reviewed. 2. The claim of entitlement to service connection for tinnitus is remanded. The Veteran contends that his tinnitus resulted from his noise exposure during deployment from 2003 to 2004. Active duty records do not document any tinnitus complaints. In an April 2004 post-deployment questionnaire, the Veteran reported often being exposed to loud noises but denied experiencing ringing in the ears currently or during deployment. The Veteran was afforded a VA hearing loss and tinnitus examination in August 2015. Regarding tinnitus, the examiner noted that the Veteran’s military exposure included explosives, heavy equipment, weapons fire, and tank weapons, reportedly without hearing protection. The Veteran reported that following service he had seven years of exposure to power plant noise but with hearing protection. The Veteran reported that he had noticeable tinnitus when he returned from Iraq in 2004. However, the examiner noted that the Veteran’s March 2004 post-deployment health assessment reflected the Veteran’s self-report that he had no ringing in his ears. The examiner noted that the Veteran’s service treatment records provided no record of tinnitus as a result of noise exposure. The examiner further noted that while there were no military audiograms, a private audiogram in March 2015 also showed hearing within normal limits with no noise-induced hearing loss. Reviewing relevant medical knowledge, the examiner observed that “only seldom does noise cause a permanent tinnitus without also causing hearing loss.” BERGER ET AL., NOISE MANUAL 125 (Fifth Ed., AIHA Press 2000). Based on these facts and this medical knowledge, the examiner concluded that a nexus could not be established linking service to current tinnitus, and that it was not at least as likely as not that the Veteran’s tinnitus was the result of in-service noise exposure. Regrettably, the VA examiner’s assessment of the record is not entirely accurate, in that there are military audiograms. The Veteran’s Reserves records were added to the claims file subsequent to the August 2015 examination, and these contain audiograms including one obtained in November 2004, proximate to the Veteran’s active duty period from 2003 to 2004. A medical opinion based on an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (per curiam). Remand is therefore required for an addendum informed by review of these additional Reserves records. The matters are REMANDED for the following actions: 1. Afford the Veteran and his representative an appropriate opportunity to submit additional evidence or argument in furtherance of the appealed claims. 2. Ensure that all outstanding VA and any pertinent private treatment records are associated with the claims file, subject to needed authorization. All actions to obtain the requested records should be documented in the claims file. Records from Gastroenterology Associates of North Florida should be obtained including any colonoscopy photographs or other documentation of internal hemorrhoids. Records should also be obtained from the primary care physician who treated the Veteran for rectal bleeding in 2011. 3. Thereafter, schedule the Veteran for an in-person VA examination by an appropriate examiner to address claimed hemorrhoids. The claims file should be reviewed, including service and post-service records, including in particular records obtained from Gastroenterology Associates of North Florida and any other private or VA treatment records for hemorrhoids. The examiner must acknowledge receipt and review of these materials. The examiner should address whether it is at least as likely as not (50 percent probability or higher) that any hemorrhoids present during the claim period developed in service or are otherwise causally related to service. In so doing, the examiner must address the August 2015 private assessment provided by S.C., PA-C, of Gastroenterology Associates of North Florida (associated with the claims file in September 2015). The Veteran’s self-reported history must also be considered. A complete rationale should be provided for all opinions. 4. Obtain an addendum medical opinion from the VA examiner who conducted the tinnitus examination in August 2015. Advise the examiner that a new opinion addressing the likelihood that tinnitus developed in service or is causal related to service is required because the August 2015 opinion relied on the supposition that there were no military audiograms. The examiner should review the Reserves treatment records which were added to the claims file in subsequent to the August 2015 examination and which include audiometric testing including in November 2004. The claims file must be made available to the examiner, and the examiner must acknowledge receipt and review of these materials. If the August 2015 examiner cannot provide an addendum, then one must be obtained from another examiner qualified to do so. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent probability or higher) that the Veteran has tinnitus which developed in service or is otherwise causally related to service. A complete rationale should be provided for all opinions. 5. Thereafter, readjudicate the remanded claims. L. CHU Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Schechter 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.