Citation Nr: 20060306 Decision Date: 09/14/20 Archive Date: 09/14/20 DOCKET NO. 17-59 757 DATE: September 14, 2020 ORDER 1. Entitlement to an effective date earlier than October 23, 2013 for the grant of a total disability rating for compensation based upon individual unemployability (TDIU) is denied. 2. Entitlement to an effective date earlier than October 23, 2013 for the grant of Dependents’ Educational Assistance (DEA) benefits under 38 U.S.C. Chapter 35 is denied. 3. Entitlement to service connection for dizziness, to include as secondary to the service-connected traumatic brain injury (TBI), is denied. REMANDED 4. Entitlement to service connection for lupus, to include as due to Isoniazid (isonicotinic acid hydrazide (INH)) injection treatment, is remanded. FINDINGS OF FACT 1. Prior to October 23, 2013, the Veteran did not meet the schedular criteria for a TDIU rating and the preponderance of the evidence is against a finding he was precluded from securing or following a substantially gainful occupation due to his service-connected disabilities. 2. Prior to October 23, 2013, the Veteran is not in receipt of a permanent and total disability rating. 3. Dizziness did not have its onset during active service and is not otherwise related to active service. To the extent that the Veteran’s symptoms of dizziness have been attributed to and otherwise overlap with his service-connected TBI, such symptoms are adequately contemplated by the disability rating currently assigned for his TBI disability, and a separate compensable disability rating for dizziness as a residual with a distinct diagnosis is not warranted. CONCLUSIONS OF LAW 1. The criteria for referral for consideration of an extraschedular TDIU rating prior to October 23, 2013 have not been met. 38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. §§ 3.340, 3.341, 3.400, 4.16(b) (2019). 2. The criteria for an effective date earlier than October 23, 2013 for the grant of Dependents’ Educational Assistance (DEA) benefits under 38 U.S.C. Chapter 35 have not been met. 38 U.S.C. §§ 3501, 5110 (2012); 38 C.F.R. §§ 3.400, 21.3020, 21.3021 (2019). 3. The criteria for service connection for dizziness, to include as secondary to the service-connected TBI, have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310, 4.14 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from May 1981 and November 1985. In May 2019, the Board denied the Veteran’s claims addressed herein, after which the Veteran appealed the matters to the United States Court of Appeals for Veterans Claims (Court). In February 2020, the parties agreed to a Joint Motion for Partial Remand (JMPR) wherein they moved the Court to vacate and remand that portion of the May 2019 Board decision regarding the claims listed above. Later that same month, the Court issued its February 2020 Order granting the JMPR. As discussed further below, the Board will addresses the deficiencies identified within the February 2020 JMPR. The Board also acknowledges that the Veteran has appealed claims for entitlement to (1) service connection for bilateral hearing loss disability and (2) an increased disability rating for right knee patellofemoral pain syndrome. In July 2020, following the issuance of a June 2020 supplemental statement of the case (SSOC) addressing those issues, the Veteran submitted VA Form 20-0996 Request for Higher-Level Review (HLR), effectively withdrawing the claims from the legacy appeals process and opting into the Appeals Modernization Act (AMA). Therefore, these claims are not before the Board and are currently awaiting adjudication via HLR by the agency of original jurisdiction. Effective Dates The effective date of an award of an increased rating is the earliest date as of which it is factually ascertainable that an increase in disability had occurred if the claim is received within one year from such date; otherwise, the effective date of the award is the later of the date of receipt of the claim or the date entitlement arose. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400(o) (2019). VA regulations allow for the assignment of an increased rating up to one year prior to receipt of a formal claim for increase, when it is factually ascertainable that an increase in disability had occurred. 38 C.F.R. § 3.400(o)(2). 1. Entitlement to an effective date earlier than October 23, 2013 for the grant of a TDIU rating. The Veteran is currently in receipt of a TDIU rating from October 23, 2013, based upon the date of receipt of his increased rating claim and the date he first met the schedular rating criteria for a TDIU. He and his attorney assert, including within a July 2020 brief, that an effective date earlier of December 19, 2012 is warranted based upon a private treatment record that they believe documents a factually ascertainable increase in disability had occurred in the year prior to the Veteran’s October 23, 2013 increased rating claim. Similarly, the parties’ February 2020 JMPR agreed that remand was warranted, as the Board previously failed to consider a December 19, 2012 medical progress note by Dr. Jeffrey R. Santi that “indicates that there may have been an increase in medication for migraine headaches” as “new medications, Treximet and Viibryd, were started for [the Veteran’s] migraine headaches.” The parties also agreed that the Board failed to properly address a May 26, 2018 opinion by a private vocational expert, Amy P. Leopold, which noted that “[the Veteran] was unable to secure or maintain substantially gainful employment to his service-connected disabilities since at least 2004, due, in part, to his headaches.” Following a careful review of the evidence of record, and as discussed further below, the Board finds that the preponderance of evidence weighs against the Veteran’s claim for an effective date earlier than October 23, 2013 for the grant of a TDIU rating. The reasons follow. Initially, the Board notes that for the one year period prior to October 23, 2013, the Veteran was service connected for migraine headaches, rated as 30 percent disabling from September 23, 2010, residual head scar, rated as 10 percent disabling from August 21, 1996, yeast infection, rated as 10 percent disabling from March 15, 2004, and right knee patellofemoral pain syndrome, rated as 20 percent disabling from February 1, 2018. Based upon the above, the Veteran’s combined disability rating prior to October 23, 2013 was 50 percent. Thus, he did not meet the schedular criteria for a TDIU rating prior to October 23, 2013. The Board is mindful that failure to meet the threshold minimum percentage standards for a TDIU rating under 38 C.F.R. § 4.16(a) does not preclude an extraschedular TDIU rating. In such cases, rating boards should refer to the Director of Compensation Service for extraschedular consideration all cases where the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disability. 38 C.F.R. § 4.16(b) (emphasis added). Additionally, although the Veteran’s attorney attempts to argue otherwise in his July 2020 brief, the Board cannot assign an extraschedular TDIU in the first instance. Rather, the Board’s analysis is limited to whether a referral to the Director of Compensation Service for consideration of an extraschedular TDIU rating is warranted. Following a careful review of the evidence of record, and as discussed below, the Board finds that the preponderance of evidence weighs against the Veteran’s claim of entitlement to an effective date earlier than October 23, 2013 for the grant of TDIU, and referral to the Director of Compensation Service for extraschedular consideration of a TDIU rating is not warranted as the preponderance of evidence is against a finding that the Veteran’s service-connected disabilities precluded him from securing or following a substantially gainful occupation prior to October 23, 2013. The Board has carefully considered the two pieces of evidence discussed within the parties’ February 2020 JMPR. The December 19, 2012 private treatment record by Dr. Santi details the Veteran’s current medications, including one 500mg tablet of Treximet taken “prn,” or, as needed, for headaches. Additionally, the Veteran was started on a sample dosage 40mg Viibryd tablet daily for migraines. To the extent that the February 2020 JMPR states that the addition of Viibryd medication may indicate that the Veteran’s service-connected migraine headaches had worsened prior to October 23, 2013, the Board points out that a review of systems conducted at the December 19, 2012 visit documents that during a review of systems of the neurologic system, the Veteran denied headaches, localized numbness, weakness, or tingling. The general examination also did not document headaches. When addressing “Assessments,” wherein Dr. Santi listed 10 assessments, he did not include an assessment related to headaches, which is consistent with the Veteran’s denial of headaches during the review of systems. Further, it appears that such medication was started because Dr. Santi had written under, “Drug Use, Long-term High-Risk Medication,” to “Stop Treximet tablet.” Thus, it appears that Dr, Santi wanted the Veteran to stop taking Treximet due to long-term high risks, which is not necessarily indicative of a worsening of the Veteran’s headaches. Moreover, a similar private treatment record from two months prior, on October 17, 2012, also documents the Veteran’s denial of new neurological symptoms, including weakness, numbness, headaches, or seizures during a review of systems. The Board affords great probative weight to the Veteran’s own lay reports within the October 2012 and December 2012 private treatment records, wherein he denied headaches, which were made for the purposes of obtaining medical treatment, and are, therefore, highly reliable. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). These two medical records do not show a worsening of the Veteran’s headaches. This is not a situation where a discussion of headaches is absent within the medical records, but rather the Veteran affirmatively denied headaches at both of these medical visits. When the RO granted the 50 percent rating for migraine headaches, effective October 23, 2013, the Veteran did not appeal the effective date assigned. Thus, the consideration before the Board is whether those clinical findings established that the Veteran was precluded from substantially gainful employment prior to October 23, 2013 due to service-connected disabilities. The clinical findings documented in the October 2012 (which is only six days beyond the one-year period) and December 2012 private medical records, where the Veteran affirmatively denied headaches at both times, is evidence against a finding that the Veteran’s headaches had worsened and/or were precluding substantially gainful employment. These facts do not warrant referral for consideration of whether the Veteran’s service-connected migraine headaches or all of the service-connected disabilities precluded substantially gainful employment prior to October 23, 2013. The Board has carefully considered the May 2018 private vocational opinion by Amy P. Leopold. Within her report, she noted that the Veteran last worked in 2004 as an industrial/crane electrician for South Carolina Port Authority. Notably, she wrote that “[a]lthough he stopped working due to a non[-]service-connected back injury, his service-connected migraines and knee condition impacted his ability to work.” Additionally, she stated that the Veteran’s migraines impacted his ability to concentrate and pay attention and also posed a significant safety risk, as the Veteran regularly worked with and around large machinery. She concluded with her opinion that “it is at least as likely as not that the combination of the Veteran’s service-connected migraines, TBI, right knee condition, chronic yeast infections, and tinnitus, as well as the resulting symptoms, restrictions, and limitations, have rendered him unable to secure and follow substantially gainful employment since 2004, when he last worked, to the present.” She continued on: “Ultimately, the Veteran was forced to stop working due to a non[-]service-connected back injury; however, it is at least as likely as not that the worsening of all of his service-connected conditions and resultant limitations has prevented him from returning to work.” The Board finds that the private vocational opinion is lacking in many respects. For example, prior to October 23, 2013, the Veteran was not service connected for TBI or tinnitus. Thus, Ms. Leopold’s finding that these two disabilities participated in precluding the Veteran from substantially gainful employment prior to October 23, 2013 is based on an inaccurate belief that the Veteran was service connected for TBI and tinnitus prior to October 23, 2013. This damages the probative value of Ms. Leopold’s opinion. Additionally, Ms. Leopold documented various records over the years that showed the Veteran complaining of headaches, which included a November 2010 VA examination report, where the Veteran reported migraines every three to four weeks, in forming her general conclusion that the Veteran’s service-connected disabilities precluded substantially gainful employment as far back as 2004. However, she did not acknowledge that the Veteran’s headaches were not always as severe as they were when the 50 percent rating was granted or as severe as the Veteran related to her when she interviewed him over the phone in 2018, when the Veteran described experiencing migraine headaches two to three times a week. Instead, she described the Veteran’s headaches as always being severe (which appears to be based on the Veteran’s January 2018 affidavit, which the Board will address separately), which misrepresents what the contemporaneous facts show. She wrote that the July 2017 VA headaches examination report showed that the Veteran reported missing two weeks of work per year due to his migraines. However, the November 2010 VA examination report that she had described within her opinion refutes this report. In addressing the Veteran’s migraine headaches, the November 2010 examiner wrote, “He did not go out of work because of the headaches.” The Board finds that what the Veteran reported to the November 2010 VA examiner highly probative, as he made this comment contemporaneously with the time period in question. Thus, Ms. Leopold’s opinion is based on another inaccurate factual premise. VA treatment records are dated as early as 1997, and they do not document the Veteran reporting that he was missing work due to headaches. In the January 2018 affidavit, the Veteran wrote he “always experienced at least two migraines a week.” He wrote that at least two times a month, he would call out of work or would have to leave early. However, the contemporaneous VA treatment records do not support this. For example, as noted above, at the time of the November 2010 VA examination, he reported having a migraine every three to four weeks and that he did not go out of work because of the headaches. Thus, what he told the VA examiner in November 2010 refutes what he wrote in the January 2018 affidavit. A July 2006 VA treatment record shows the Veteran reported getting headaches two times a month, which is not two migraine headaches a week. Thus, the facts alleged by the Veteran in the January 2018 affidavit are inaccurate and not credible. Thus, to the extent that Ms. Leopold relied on these facts, her opinion has no probative value. In the May 2018 private opinion, Ms. Leopold wrote that the Veteran’s yeast infections were “very distracting at work and when he attempts to focus on tasks,” which she based on the Veteran’s January 2018 affidavit. The Veteran had written in the affidavit that the skin problem took away his ability to give “any type of productive attention” to his tasks at work. However, in the November 2010 VA examination report, the examiner wrote that the Veteran “did not [miss] a lot of work because of the tinea versicolor. He has no functional limitations related to the tinea versicolor.” The Board notes that there is a word missing from the November 2010 VA examination report, and, based on what the examiner wrote, the Board finds it reasonable to conclude that the missing word is “miss” or something to that effect. The Veteran was informing the examiner that the skin disability was not causing him functional impairment and that it did not cause sufficient functional impairment for him to miss “a lot of work.” An April 2004 VA examination report shows that the Veteran reported his skin disability was treated with Zyrtec, and that as long as he took one every day, he would not get eruptions. The Board finds that the Veteran’s allegations in the January 2018 affidavit as to the severity of his skin disability are not credible. As a result of these findings, the Board accords no probative value to Ms. Leopold’s opinion, as her opinion is based on multiple, inaccurate facts. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Additionally, it must be noted that the Veteran’s claim for a TDIU rating is based upon the claim for increase he submitted on October 23, 2013. Thus, even if the Veteran was precluded from substantially gainful employment due to service-connected disabilities as far back as 2004, this would not establish entitlement to an effective date earlier than October 23, 2013, as the increase in disability was beyond the one-year period, which then places the date of claim as the proper effective date for the award of an increased rating. See Gaston v. Shinseki, 605 F.3d 979, 983 (Fed. Cir. 2010) (“It is clear from the plain language of 38 U.S.C. § 5110(b)(2) that it only permits an earlier effective date for increased disability compensation if that disability increased during the one-year period before the filing of the claim.”). In sum, based upon the above, and following a careful review of the evidence of record, the Board concludes that the preponderance of the evidence is against a finding that the Veteran was precluded from securing or following a substantially gainful occupation consistent with his education and vocational history as an electrician due to his service-connected disabilities prior to October 23, 2013, to include the one-year period prior to October 23, 2013. For all these reasons, the Board finds that referral for consideration of an extraschedular TDIU rating prior to October 23, 2013 is not warranted. 2. Entitlement to an effective date earlier than October 23, 2013 for the grant of DEA benefits under 38 U.S.C. Chapter 35. The Veteran also claims entitlement to an effective date prior to October 23, 2013 for the grant of eligibility for DEA benefits under 38 U.S.C. Chapter 35. Essentially, his claim in this regard stems from his claim above regarding an effective date earlier for the grant of a TDIU. As noted within the parties’ February 2020 JMPR, the issue of an effective date earlier for DEA was inextricably intertwined with the claim of entitlement to an effective date earlier than October 23, 2013 for the award of TDIU. Educational assistance is payable to the dependent children or spouses of veterans under certain circumstances; the existence of a permanent and total disability rating for service-connected disability is a requirement for eligibility for DEA benefits. 38 U.S.C. §§ 3500, 3501 (2012); 38 C.F.R. §§ 3.807(a), 21.3021. A total disability may be assigned where a veteran’s service-connected disabilities are rated as 100 percent disabling under the rating schedule, or if the veteran is unemployable due to service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341. In this case, the effective date for the award of DEA benefits is October 23, 2013, as this was the date the evidence showed the Veteran to have a total service-connected disability permanent in nature, due to the grant of a TDIU rating effective that same date. As discussed above, an effective date earlier prior to October 23, 2013 for the grant of a TDIU is not warranted. As such, prior to October 23, 2013, the Veteran’s combined disability rating was 50 percent; therefore, a total disability rating was not in effect for the Veteran’s service-connected disabilities prior to that date. DEA benefits may not be awarded prior to the effective date of an award for a permanent and total disability rating. 38 U.S.C. §§ 3501, 3510. As such, the Board finds that the Veteran’s claim must be denied as a matter of law, there is no reasonable doubt to be resolved, and the Veteran is not entitled to an effective date earlier than October 23, 2013 for DEA benefits under Chapter 35. 3. Entitlement to service connection for dizziness, to include as secondary to the service-connected TBI. The Veteran also claims that he is entitled to a separate compensable disability rating for dizziness as secondary to his service-connected TBI. The parties’ February 2020 JMPR noted that the Board previously denied service connection for dizziness because the Veteran did not have a “separately diagnosed condition manifested as dizziness and has not had one at any time during the pendency of the appeal or recent to the filing of the claim.” However, the parties stated that Diagnostic Code (DC) 8045 requires that the Board evaluate physical residuals of TBI, such as coordination and balance problems, which would include dizziness, under an appropriate DC. See 38 C.F.R. § 4.124a. There is no requirement in DC 8045 that physical effects, such as gait and coordination, which are to be rated under an appropriate DC, be separately diagnosed. Additionally, the parties also noted that the Board had already conceded that the Veteran’s dizziness was indeed a symptom of his TBI, and it did not compensate for dizziness when it granted an increased 10 percent disability rating for TBI. As such, they agreed that remand was warranted for the Board to address whether the Veteran is entitled to additional compensation for dizziness, as required by 38 C.F.R. § 4.124a. Following a review of the evidence of record, the Board finds that the preponderance of evidence weighs against the Veteran’s claim of entitlement to service connection for dizziness, to include as secondary to the service-connected TBI. Specifically, as discussed below, the Board finds that the Veteran is not entitled to additional compensation or a separate disability rating for his dizziness as a symptom of his service-connected TBI. The Veteran is currently service connected for TBI rated as 10 percent disabling from October 23, 2013 pursuant to DC 8045. 38 C.F.R. § 4.124a, DC 8045 (2019). Thereunder, the main areas of dysfunction that may result from TBI include cognitive impairment, subjective symptoms, emotional/behavioral dysfunction, and physical dysfunction. Cognitive impairment, which is defined as decreased memory, concentration, attention, and executive functions of the brain, is evaluated under the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” Subjective symptoms are evaluated under the subjective symptoms facet in the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified;” however, any residual “with a distinct diagnosis” that may be evaluated under another diagnostic code is to be separately evaluated. (emphasis added). Emotional/behavioral dysfunction is evaluated under 38 C.F.R. § 4.130 (2019) when there is a diagnosis of a mental disorder; however, when there is no diagnosis of a mental disorder, emotional/behavioral symptoms are evaluated under the criteria in the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” Physical (including neurological) dysfunction is evaluated based on the following list, under an appropriate diagnostic code: Motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. The table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” contains 10 important facets of TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from “0” to “3,” and level “5,” the highest level of impairment, labeled total. However, not every facet has every level of severity. For example, the Consciousness facet does not provide for an impairment level other than total, since any level of impaired consciousness would be totally disabling. A 100 percent disability rating is warranted for a total evaluation for one or more facets. If no facet is evaluated as total, an overall percentage rating based on the level of the highest facet is assigned as follows: “0” = 0 percent; “1” = 10 percent; “2” = 40 percent; and “3” = 70 percent. For example, if “3” is the highest level of evaluation for any facet, a 70 percent rating is warranted. As noted above, the Board has previously conceded that the Veteran’s complaints of dizziness are a residual of his TBI. DC 8045 specifically contemplates such complaints under level “1” impairment for subjective symptoms, including “intermittent dizziness.” However, as discussed below, a review of the evidence of record reveals no objective or subjective evidence warranting greater than level “1” impairment for any facet from October 23, 2013. VA treatment records from May 2013 document that the Veteran reported issues with memory, sleep, impulsivity, irritability, dizziness, and headaches since an in-service head injury. Thereafter, in August 2013, he was noted to have problems with short-term and long-term memory, focus, and concentration. A December 2013 letter from a private physician, Dr. Jeffrey R. Santi, noted that he had treated the Veteran for “several years” and that he had chronic dizziness, headaches, and tinnitus related to his in-service head injury based on the Veteran’s consistent report of the onset of symptoms in service. Upon VA examination in April 2014, the Veteran reported an in-service head injury that resulted in headaches that had continued, though the VA examiner noted that the Veteran did not appear to have any other significant sequelae based on his report. Notably, the VA examiner assigned a facets evaluation of “0” for memory, attention, concentration, executive function, judgment, social interaction, orientation, motor activity, subjective symptoms, neurobehavioral effects, and communication. Significantly, the only TBI residual noted was the Veteran’s headaches. Thereafter, in November 2014, the Veteran reported that his TBI resulted in confusion and disorientation that led to him frequently getting lost when driving. Additionally, he reported problems with memory, concentration, and focus, including difficulty remembering people and places. During a May 2016 Neurology Consultation, the Veteran was described as alert and oriented with a normal attention span and knowledge base, and he was able to name the president and presidential candidates; however, he complained of baseline memory loss and episodes of confusion and word finding, and he was referred to the memory clinic. During a July 2017 VA examination, the Veteran reported headaches, dizziness, nausea, and confusion after his in-service head injury. The VA examiner assigned a facets evaluation of “1” for Memory, attention, concentration, and executive functions, noting the Veteran’s reports of difficulty with memory, including his report that he was unable to remember what he had for breakfast or where he put things. A facets evaluation of “0” was assigned for Judgment, Social Interaction, Orientation, and Motor activity. For subjective symptoms, a facets evaluation of “1” was assigned, accounting for depression, headaches, and vertigo. A facets evaluation of “1” was also assigned for Neurobehavioral effects, indicating that the Veteran was easily distracted and impulsive, as the Veteran noted that it was difficult to plan things and follow through. A facets evaluation of “0” was assigned for Communication. Consciousness was normal. The examiner noted the Veteran’s headaches but found no other pertinent physical findings or associated symptoms. Based on a review of the above, even when specifically and properly considering the Veteran’s complaints of dizziness in the context of his TBI as level “1” impairment for subjective symptoms, including “intermittent dizziness,” the Board finds that such complaints do not warrant the assignment of an additional compensable disability rating, including a compensable 10 percent or 30 percent disability rating for dizziness as a symptom of peripheral vestibular disorders under DC 6204, as asserted by the Veteran’s attorney within his July 2020 brief. 38 C.F.R. § 4.87, DC 6204 (2019). As noted above, DC 8045 specifically notes that any residual “with a distinct diagnosis” that may be evaluated under another diagnostic code is to be separately evaluated; however, the Board finds as fact that the Veteran’s dizziness has not resulted in a “distinct diagnosis,” including peripheral vestibular disorder. Additionally, the Board finds that the probative evidence of record, including as discussed above, documents no worse than level “1” for any facets according to the “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” table. As such, a separate compensable disability rating or an increased disability rating in excess of 10 percent is not warranted based upon the Veteran’s residual dizziness. Accordingly, the Board finds that the preponderance of the evidence weighs against the Veteran’s claim of entitlement to service connection and/or a separate compensable disability rating for dizziness, to include as secondary to the service-connected TBI. As such, there is no reasonable doubt to be resolved, and the claim is denied. REASONS FOR REMAND 4. Entitlement to service connection for lupus, to include as due to Isoniazid (isonicotinic acid hydrazide (INH)) injection treatment, is remanded. Following a review of the evidence of record, the Board finds that remand is warranted regarding the Veteran’s claim of entitlement to service connection for lupus, to include as due to INH injection treatment, for additional development. Specifically, the Board finds that an adequate medical opinion must be obtained in order to comply with the parties’ February 2020 JMPR. Within the February 2020 JMPR, the parties’ agreed that the Board erroneously relied on a November 2015 VA opinion, which found that although there was some association between INH injections and lupus like symptoms, research did not show such development more than 20 years after completion of INH. Notably, in a November 2018 response to a Supplemental Statement of the Case (SSOC), the Veteran’s representative cited to articles showing that the most common signs of lupus include an unexplained rash and gastrointestinal problems; however, the November 2015 VA examiner did not address such articles or the Veteran’s in-service complaints of stomach pain, persistent tension, itching, and rash to determine if they supported a nexus between his current condition and his service. Additionally, the Board also did not address the articles submitted by Appellant to determine whether the Veteran’s in-service symptomatology showed that his in-service lupus stemmed from in-service INH treatment and showed a nexus between his current condition and his active service. Given the above, an adequate addendum opinion should be obtained upon remand. The matters are REMANDED for the following action: Obtain an addendum medical opinion from the same VA examiner who provided the November 2015 VA examination and opinion, or an equally qualified and appropriate VA examiner, regarding the Veteran's claim of entitlement to service connection for lupus, to include as due to INH injection treatments. If the VA examiner believes that an in-person examination is warranted in order to provide the requested opinion, including a supporting rationale for the opinion, then schedule the Veteran for an in-person VA medical examination, with adequate prior notice of the examination date and location sent to the Veteran and his attorney. In order to assist the VA examiner with his or her review of the record, the Board invites the examiner’s attention to the following facts with citations to the records, where applicable: • The Veteran had active service from May 1981 and November 1985. • Service treatment records show that the Veteran had a positive PPD test in June 1981. The plan was to have him undergo INH treatment for one year. See VBMS entry with document type, “STR – Medical,” receipt date 08/21/1996, at page 7. • Service treatment records document the Veteran’s complaints of a rash, itching, stomach pain, and tension during active service. See VBMS entry with document type, “STR – Medical,” receipt date 08/21/1996, at pages 45 (February 1, 1985 showing complaints of itching and tension), 61 (June 1, 1984 showing complaint of stomach pain), and 73 (October 28, 1981 noting complaint of rash). • The Veteran believes that these in-service symptoms were indicative of lupus after undergoing the INH treatment. • A November 2015 VA opinion found that although there was some association between INH injections and lupus-like symptoms, research did not show such development more than 20 years after completion of INH treatment. See VBMS entry with document type, “C&P Exam,” receipt date 11/02/2015. • Within a November 2018 SSOC response, the Veteran’s representative cited to articles showing that the most common signs of lupus include an unexplained rash and gastrointestinal problems. (“Common signs and symptoms of lupus include, but are not limited to, rashes and gastrointestinal problems. Lupus, Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/lupus/symtoms-causes/syc-20365789; and 10 early signs of Lupus, Healthline, https://www.healthline.com/health/lupus/early-signs#rash.”). See VBMS entry with document type, “Third Party Correspondence,” receipt date 11/01/2018. • The examiner’s review of the record is NOT restricted to the evidence listed above. This list is provided in an effort to assist the examiner in locating potentially relevant evidence. The examiner is asked to opine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s lupus is related to active service, to include as due to INH injection treatments. In rendering the requested opinion, the examiner should specifically consider, discuss, and reconcile the relevant evidence of record, including the following: service treatment records documenting the Veteran’s relevant in-service complaints of a rash, itching, stomach pain, and tension; the November 2015 VA opinion; and the articles referenced by the Veteran’s representative in November 2018 showing that the most common signs of lupus include an unexplained rash and gastrointestinal problems. A full rationale, including reference to supporting clinical data and/or medical literature as deemed appropriate, must be provided for all medical opinions given. If the examiner is unable to provide an opinion without resorting to mere speculation, he or she should explain why this is so. The examiner shall then explain whether the inability to provide a more definitive opinion is the result of a need for more information and indicate what additional evidence is necessary, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Chad Johnson, 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.