Citation Nr: 20026078 Decision Date: 04/15/20 Archive Date: 04/15/20 DOCKET NO. 19-29 655 DATE: April 15, 2020 REMANDED Entitlement to service connection for restless leg syndrome is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from August 1992 until his honorable discharge in August 1996. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a December 2018 rating decision by the Oakland, California Regional Office (RO) of the United States Department of Veterans Affairs (VA). 1. Entitlement to service connection for restless leg syndrome is remanded. The Veteran asserts that his restless leg syndrome began in service, and/or was caused by his use of mefloquine during service. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Generally, a medical opinion should address the appropriate theories of entitlement. Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). The Veteran was afforded a VA examination in November 2018. The November 2018 VA examiner opined that the Veteran’s restless leg syndrome was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness because although the Food and Drug Administration (FDA) Black Box warning regarding mefloquine includes dizziness, loss of balance, and tinnitus, it does not extend to restless leg syndrome and the Veteran’s claim of neurotoxicity by mefloquine as a causative factor. However, the Board notes that although the November 2018 VA examiner offered clear conclusions, they did not provide sufficient supporting data and a reasoned (and detailed) medical explanation connecting the two, and also did not address the conclusions or rationale of the September 2018 private provider opinion. Furthermore, the Board notes that the VA examiner has not offered an opinion if any of the Veteran’s service-connected disabilities may have caused or aggravated the Veteran’s restless leg syndrome. The explanations contained in the private provider opinion indicate that the Veteran’s service-connected disabilities may be associated with the Veteran’s restless leg syndrome and it must be addressed. The Veteran underwent private provider evaluations in September 2018 (received in October 2018) and June 2019 (received in July 2019). The private provider opined that the Veteran’s restless leg syndrome is at least as likely as not (50 percent probability or greater) incurred in or caused by the claimed in-service injury, event, or illness. The private provider noted that mefloquine has been reported to be associated with the development of myoclonus, particularly during sleep, consistent with periodic limb movements during sleep, and can contribute to a diagnosis of restless leg syndrome. However, the private provider does not assert that the mefloquine causes restless leg syndrome and that the mere association of such with the development of myoclonus can (the mere possibly) contribute to a diagnosis of restless leg syndrome does not rise to the level of at least as likely as not. Furthermore, although the private provider continues to assert that it is at least as likely as not (50 percent probability or greater) that the Veteran’s symptoms of insomnia, restlessness, and periodic limb movements during sleep, all of which developed following his use of mefloquine, are primarily the direct causal result of his exposure to mefloquine; that the exposure to mefloquine provides the single most parsimonious explanation for the onset and persistence of those symptoms, that there are no more likely causes; and the VA has not proposed a more likely cause for the onset of these symptoms, the Board has concerns with the adequacy and sufficiency of the opinion. First, the private provider qualifies his opinion as the most “parsimonious” explanation for the onset and persistence of those symptoms. The qualification of an unwillingness to spend money or use resources (provide additional testing, investigation, or research) is not a valid rationale to justify a conclusory opinion. Second, the private provider does not explain why the Veteran’s symptoms of insomnia, restlessness, and periodic limb movements during sleep are directly caused by the Veteran’s use of mefloquine during service beyond noting that it has been reported that those symptoms may be associated with the use of mefloquine (not caused by), or why those specific symptoms have subsequently caused the Veteran’s restless leg syndrome. The mere possibility of a cause, let alone the mere possibility of an association, is not a valid rationale to justify a conclusory opinion. Third, the rationale that that there are no more likely causes and the VA has not proposed a more likely cause for the onset of these symptoms is not a valid rationale to justify a conclusory opinion. Given the Board’s concerns, the Veteran is certainly free and encouraged to obtain a supplemental opinion from this provider. For the above reasons, remand is required to obtain an addendum opinion regarding the etiology of the Veteran’s restless leg syndrome. The matters are REMANDED for the following action: 1. Obtain an addendum opinion regarding the etiology of the Veteran’s restless leg syndrome from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s restless leg syndrome had onset in, was aggravated by, or is otherwise related to, active service; including but not limited to as secondary to a service-connected disability. The examiner must specifically address the following: (a) The September 2018 private provider opinion, received October 30, 2018; (b) The June 2019 private provider supplemental opinion, received July 15, 2019; (c) An explanation or clarification as to the significance of the FDA’s black box warning and that it does not extend to restless leg syndrome (see the November 2018 VA examination at 3C), that the examiner determined that; (d) The likelihood of delayed onset of restless leg syndrome (in 2000, at the earliest) compared to exposure mefloquine during service, which he was discharged in 1996. (Continued on the next page)   (e) The Veteran’s lay statements concerning onset of symptomatology in conjunction with the private provider’s opinions on those symptoms causing the Veteran’s restless leg syndrome. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Deemer, 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.