Citation Nr: 21004114 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 12-03 475 DATE: January 26, 2021 REMANDED Entitlement to service connection for temporomandibular joint (TMJ) syndrome is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD), claimed as acid reflux, is remanded. Entitlement to service connection for fibromyalgia is remanded. Entitlement to an initial rating in excess of 30 percent for major depressive disorder is remanded. REASONS FOR REMAND The Veteran had active service from September 1994 to May 1999. The Board previously remanded the issues of entitlement to service connection for TMJ syndrome, entitlement to service connection for GERD, and entitlement to a higher initial rating for major depressive disorder in July 2014. 1. Entitlement to service connection for TMJ syndrome is remanded. The Veteran contends that her TMJ syndrome is due to an in-service motor vehicle accident or is secondary to her service-connected cervical spine disability or service-connected major depressive disorder. Her service treatment records confirm that she suffered whiplash injuries in a September 1997 motor vehicle accident. The Veteran has also submitted evidence indicating that TMJ syndrome may be caused by stress from her service-connected disabilities. In its July 2014 remand, the Board directed the Agency of Original Jurisdiction (AOJ) to provide the Veteran a VA examination as to her claimed TMJ syndrome. The Board asked that the VA examiner provide opinions as to whether the Veteran’s current TMJ syndrome may be related to the in-service motor vehicle accident or may be caused or aggravated by the service-connected cervical spine disability or the service-connected major depressive disorder. Pursuant to the July 2014 remand, the Veteran was provided a VA TMJ conditions examination in June 2015. However, in that examination report, the examiner provided only conclusory opinions that were not supported by appropriate rationale. Therefore, an addendum opinion was obtained from the same examiner in April 2017. In the addendum opinion, the examiner opined that it is less likely than not that the Veteran’s TMJ syndrome had its onset during her active service, is otherwise related to her active service, or was caused or aggravated by the service-connected major depressive disorder. As a rationale for that opinion, the examiner explained, “There was no evidence in the [service treatment records] that her TMJ symptoms began during or were related to her active duty service. Based on current medical and dental literature there is no causal relationship between TMJ symptoms and depressive disorder. The current TMJ symptoms were not caused by or aggravated by her depression.” The Board finds the April 2017 opinion to be inadequate for decision-making purposes because it does not discuss the in-service motor vehicle accident and resulting whiplash injuries, does not discuss the evidence submitted by the Veteran indicating that her TMJ syndrome may be related to stress from her service-connected disabilities, and does not address whether the Veteran’s TMJ syndrome may be caused or aggravated by her service-connected cervical spine disability. Therefore, the issue must be remanded so that another addendum opinion may be obtained. 2. Entitlement to service connection for GERD is remanded. The Veteran contends that her GERD is secondary to her service-connected major depressive disorder or service-connected irritable bowel syndrome. In the July 2014 remand, the Board directed the AOJ to provide the Veteran a VA examination as to her claimed GERD. The Board asked that the VA examiner provide opinions as to whether the Veteran’s current GERD had its onset in service, is otherwise related to her active service, or is caused or aggravated by her service-connected irritable bowel syndrome and/or her service-connected major depressive disorder. Pursuant to the July 2014 remand, the Veteran was provided a VA esophageal conditions examination in June 2015. The June 2015 VA examiner opined that the GERD and gastroparesis are less likely as not related to service or other service-connected conditions and is not aggravated by those conditions. As a rationale for that opinion, she stated, “I found no indication of symptoms or treatment for this in her [service treatment records]. She was diagnosed with GERD many years post service. She was diagnosed with gastroparesis which causes some of her symptoms many years post service.” The examiner did not provide any rationale for the opinion that the Veteran’s GERD and gastroparesis are not secondary to her service-connected disabilities. Therefore, the opinion is inadequate for decision-making purposes, and the issue must be remanded so that an addendum opinion may be obtained. 3. Entitlement to service connection for fibromyalgia is remanded. The Veteran asserts that her fibromyalgia is secondary to her service-connected irritable bowel syndrome. She was afforded a VA fibromyalgia examination in September 2015. The September 2015 VA examiner opined that the Veteran’s fibromyalgia is not at least as likely as not proximately due to or the result of her irritable bowel syndrome. However, she did not provide an opinion as to whether the Veteran’s irritable bowel syndrome may have aggravated her fibromyalgia. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). Therefore, the issue must be remanded so that an addendum opinion may be obtained. In addition, the Veteran has submitted statements from A. McCarthy, M.D. and N.Levitt, M.D., who say they treat the Veteran for her fibromyalgia. On remand, efforts should be made to obtain records from Dr. McCarthy and Dr. Levitt.   4. Entitlement to an initial rating in excess of 30 percent for major depressive disorder is remanded. The record shows that the Veteran’s mental health symptoms may have significantly worsened since she was most recently provided a VA examination as to her service-connected major depressive disorder in June 2015. They also show that the Veteran has been diagnosed with other psychiatric disabilities, to include posttraumatic stress disorder (PTSD), which have not been service connected. The Board finds that the issue must be remanded so that the Veteran may be provided a VA examination to determine the current severity of her service-connected major depressive disorder and, if possible, specify which of her mental health symptoms are caused by her service-connected major depressive disorder and which are caused by nonservice-connected psychiatric disabilities. In addition, the Veteran has submitted a statement by a psychiatric physician assistant and a therapist at Advanced Counseling Services indicating that the Veteran has received psychiatric treatment at that private facility. On remand, efforts should be made to obtain records from Advanced Services. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for Dr. A. McCarthy and Dr. N. Levitt, who have treated her for fibromyalgia, and for Advanced Counseling Services. Make two requests for any records identified and authorized for release, unless it is clear after the first request that a second request would be futile. Notify the Veteran of any inability to obtain such records. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s TMJ syndrome at least as likely as not (50 percent probability or greater) is related to the in-service motor vehicle accident and associated whiplash injury, or is proximately due to or aggravated beyond its natural progression by service-connected disability, to include the service-connected irritable bowel syndrome and service-connected cervical spine disability. The examiner must address the internet-based information submitted by the Veteran that states, “Stress frequently leads to unreleased nervous energy. It is very common for people under stress to release this nervous energy by either consciously or unconsciously grinding or clenching their teeth”, and the Veteran’s assertions that her service-connected disabilities cause stress. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s GERD at least as likely as not (50 percent probability or greater) is proximately due to or aggravated beyond its natural progression by a service-connected disability, to include the service-connected irritable bowel syndrome and major depressive disorder. The opinion must be supported by adequate rationale. An opinion is adequate when it is factually accurate, fully articulated, and soundly reasoned. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Prejean v. West, 13 Vet. App. 444 (2000). 4. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s fibromyalgia at least as likely as not (50 percent probability or greater) is proximately due to or aggravated beyond its natural progression by a service-connected disability, to include the service-connected irritable bowel syndrome. The examiner should discuss the Veteran’s former representative’s assertion that the Veteran’s fibromyalgia “may be related” to vitamin deficiencies caused by her service-connected irritable bowel syndrome. 5. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of her service-connected major depressive disorder. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to her service-connected major depressive disorder alone and should differentiate those symptoms from symptoms caused by the Veteran’s diagnosed nonservice-connected psychiatric disabilities, which include PTSD. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. J. Anthony, 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.