Citation Nr: 20029902 Decision Date: 04/28/20 Archive Date: 04/28/20 DOCKET NO. 15-21 537 DATE: April 28, 2020 REMANDED Issue of entitlement to service connection for a joint condition (claimed as pain) is remanded. Issue of entitlement to service connection for gastritis with weight loss is remanded. Issue of entitlement to service connection for migraine headaches is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1989 to May 1992. The Veteran is a Persian Gulf veteran. This appeal to the Board of Veterans’ Appeals (Board) arose from a January 2013 rating decision issued by the Department of Veterans Affairs (VA). See February 2013 Notice of Disagreement (NOD); May 2015 Statement of the Case (SOC); May 2015 Substantive Appeal (VA Form 9). The Veteran testified before the undersigned Veterans Law Judge in a May 2018 hearing. See May 2018 Hearing transcript. In July 2018, the Board found new and material evidence to warrant granting the Veteran’s request to reopen his claim of entitlement to service connection for migraine headaches. July 2018 Board decision. The Board remanded the issue of entitlement to service connection for migraine headaches with the other claims above for further development by the Agency of Original Jurisdiction (AOJ). Id. The Board finds that there has been substantial compliance with its remand directives. The AOJ denied the Veteran’s claims. February 2020 Supplemental Statement of the Case (SSOC). The claims are now back before the Board. 1. Issue of entitlement to service connection for a joint condition (claimed as pain) is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for a joint condition because clarification is needed by a VA examiner as to the nature and cause of the Veteran’s joint pain complaints. The Veteran asserts joint pain due to “gulf war syndrome.” See September 2012 VA Form 21 526EZ; September 2012 VA Form 21 4138. A January 2013 VA examiner opined that the Veteran’s joint pain is not an undiagnosed illness or diagnosed medically unexplained chronic multisystem illness (MUCMI), but most consistent with somatization or symptoms magnification. See January 2013 VA examination. The January 2013 VA examiner’s rationale for a somatization disorder suggests lack of certainty for the diagnosis. Moreover, it is unclear from the opinion if a somatization disorder has at least a partially understood etiology and pathophysiology and, thus, not considered a MUCMI. In addition, VA treatment records show that the Veteran has been diagnosed with a “pain disorder exclusively related to psychological factors.” December 2015 VA treatment evidence. If the Veteran has a current somatization disorder or pain disorder, it is unclear if the symptoms are distinguishable from his Veteran’s service connected PTSD or if his pain complaints are secondary to his PTSD. The Board finds that an evaluation of the Veteran’s joint pain complaints by a mental health professional is needed. 2. Issue of entitlement to service connection for gastritis with weight loss is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for gastritis and weight loss because clarification is needed by a VA examiner as to the nature and cause of the Veteran’s gastritis and weight loss complaints. The Veteran asserts gastritis and weight loss due to “gulf war syndrome.” See September 2012 VA Form 21 526EZ; September 2012 VA Form 21 4138. The January 2013 VA examiner opined that the Veteran’s gastritis and weight loss are not an undiagnosed illness or diagnosed MUCMI, but consistent with medication related gastritis which then caused his periods of weight loss. January 2013 VA examination. However, the VA examiner noted that the Veteran had no treatment for gastritis during service in support of her opinion, but it is unclear if or how the VA examiner consider the service treatment records showing the Veteran was seen for loose stools and abdominal pain. See February 1990 Service treatment record; July 1991 Service treatment record; March 1992 Service treatment record. In addition, the Veteran testified that he stopped taking opiates and still has gastritis symptoms. May 2018 Hearing transcript. The Board finds that an addendum opinion is needed from a VA examiner. 3. Issue of entitlement to service connection for migraine headaches is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for migraine headaches because clarification is needed by a VA examiner as to the nature and cause of the Veteran’s migraine headache complaints. The Veteran asserts his migraine headaches are due to “gulf war syndrome.” See September 2012 VA Form 21 526EZ; September 2012 VA Form 21 4138. A January 2013 VA examiner opined that there is no undiagnosed illness or diagnosed MUCMI because the Veteran has a known migraine diagnosis that is due to a post-service motor vehicle accident in 1996-1997 or toxin exposure while working as an exterminator in 1997. January 2013 VA examination. However, VA treatment evidence suggests that the Veteran’s service connected PTSD may be “contributing at least to his headaches.” October 2003. The VA treatment provider did not explain how PTSD contributes to the Veteran’s migraine headaches and it is unclear if the Veteran’s PTSD affects the Veteran’s migraine headaches during the period on appeal. The Board finds that an addendum opinion is needed. The matters are REMANDED for the following action: 1. Obtain a VA medical opinion by an appropriate mental health professional and, if needed, by a medical professional, to determine the nature and cause of any joint pain, including as due to “gulf war syndrome,” a somatoform disorder, or pain disorder due to psychological factors. If deemed necessary by the mental health and/or medical professional, afford the Veteran a VA examination. The mental health and/or medical professional should respond to the following: (a) Are there objective indications (including symptoms reported by the Veteran) that the Veteran has joint pain? If so, the examiner must determine whether any identified join pain signs or symptoms can be attributed to a known clinical diagnosis with both a conclusive pathophysiology and etiology. The examiner should consider and discuss the January 2013 VA examination report’s finding that the Veteran’s joint pain is due to a somatoform disorder, and the December 2015 VA treatment evidence noting a diagnosis for “pain disorder exclusively related to psychological factors.” If the examiner finds that the evidence supports a diagnosis for a somatoform disorder, provide a specific opinion on whether the Veteran’s somatoform disorder has at least a partially understood pathophysiology as well as etiology. A detailed explanation (rationale) is requested, including citing to supporting clinical data (and/or medical literature), as appropriate. (b) For those symptoms and conditions of joint pain that cannot be attributed to a known clinical diagnosis with conclusive pathophysiology and etiology, the examiner must determine if there is affirmative evidence that the joint pain was caused by a supervening condition or event that occurred since the Veteran’s separation from service. The VA examiner should specifically address the Veteran’s February 28, 2012 VA treatment for back and neck pain due to a prior falls and injuries. 2. Obtain an addendum opinion from an appropriate medical professional to determine the nature and cause of the Veteran’s asserted gastritis with weight loss due to “gulf war syndrome.” If possible, obtain an opinion from the same medical professional who provided the January 2013 Gulf War general examination. If the medical professional determines that it is necessary, schedule the Veteran for another VA examination. The medical professional should respond to the following: (a) Identify any objective indications (including symptoms reported by the Veteran) that the Veteran has gastritis with weight loss. The examiner must determine whether these symptoms can be attributed to a known clinical diagnosis with at least a partially understood pathophysiology as well as etiology. The examiner should consider the Veteran’s May 2018 testimony that he stopped using opiates, but still had gastritis. .(b) For those symptoms and conditions that cannot be attributed to a known clinical diagnosis with conclusive pathophysiology and etiology, the examiner must determine if there is affirmative evidence that the Veteran’s gastritis, weight loss, or migraine headaches were caused by a supervening condition or event that occurred since separation. (c) If the examiner determines that the Veteran’s gastritis with weight loss is not an undiagnosed illness or a MUCMI, then provided an opinion on whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s gastritis with weight loss began in (or is otherwise related to) the Veteran’s military service? The examiner should consider and discuss the Veteran’s lay testimony and assertions regarding any pertinent complaints and symptoms. The examiner should consider and discuss the February 19, 1990 service treatment record showing the Veteran was seen for nausea, vomiting, and diarrhea. The examiner should also consider the July 24, 1991 and March 20, 1992 service treatment records that also show treatment for stomach symptoms. A detailed explanation (rationale) is requested, including citing to supporting clinical data (and/or medical literature), as appropriate. 3. Obtain an addendum opinion from one or more appropriate medical professionals to determine the nature and cause of the Veteran’s current migraine headaches. A detailed explanation (rationale) is requested, including citing to supporting clinical data (and/or medical literature), as appropriate. If the medical professional(s) determine that it is necessary, schedule the Veteran for a VA examination. The medical professional(s) should respond to the following: (a) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s current migraine headache began in (or is otherwise related to) the Veteran’s military service? (b) If found not directly related to service, the examiner(s) should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s current migraine headaches are proximately due to or the result of his service connected disabilities, including PTSD. If the examiner(s) find the Veteran’s migraine headaches are not proximately due to or the result of PTSD, the examiner(s) should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s current migraine headaches are aggravated (permanently made worse) by one or more service connected disabilities, to specifically include PTSD. The examiner(s) should an October 22, 2003 VA treatment record indicating that the Veteran’s PTSD contributes to his headaches. (c) If the Veteran’s current migraine headaches are deemed to be unrelated to service or one or more service connected disabilities, the examiner should, if possible, identify the cause considered more likely and explained why that is so. 4. Review the record and ensure that all development sought in this remand has been completed. Arrange for any further development indicated by the results of the development requested above if deemed warranted by the AOJ, and re-adjudicate the claim(s). If the claim is denied, supply the Veteran and his representative with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review, if otherwise in order. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Department of Veterans Affairs 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.