Citation Nr: 21061948 Decision Date: 10/05/21 Archive Date: 10/05/21 DOCKET NO. 14-25 352A DATE: October 5, 2021 REMANDED Entitlement to service connection for hemorrhoids is remanded. REASONS FOR REMAND The appellant served on active duty in in the United States Army from August 1989 to August 1991. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) which denied the claims on appeal. This decision was appealed in a notice of disagreement (NOD) received by VA in July 2012. A Statement of the Case (SOC) was issued by VA in June 2014. VA received the appellant's Substantive Appeal (Form 9) in July 2014, perfecting the appeal, and requesting a hearing before the Board. In June 2018, the appellant presented sworn testimony during a videoconference hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the appellant's VA claims file. This claim was previously remanded by the Board in an October 2018 decision for further development. A Supplemental Statement of the Case (SSOC) was issued by VA in February 2021. The Board most recently remanded this issue in March 2021 so that VA could fulfill its duty to assist in obtaining a medical opinion regarding the etiology of the appellant's disability. Additional SSOCs were issued by VA in April 2021 and August 2021. As an initial matter, the Board notes that the appellant's entire claims file was lost during the pendency of the appeal. A January 2017 memorandum from the Agency of Original Jurisdiction (AOJ) indicated that multiple unsuccessful searches for the claims file were conducted. The RO thereafter attempted to rebuild the appellant's claims file. The rebuilt file does not include the June 2014 SOC pertaining to the claims on appeal. In addition, the notification letter for the July 2012 rating decision indicates that the Veteran submitted a private nexus opinion in support of his hemorrhoid claim; these nexus opinions have not been recovered. The appellant's service treatment records also appear to be incomplete, as they do not include records of a separation examination. Efforts to locate these missing records were undertaken after the Board's October 2018 remand of this claim but have proved unsuccessful. The appellant was notified of this in an October 2019 letter and given an opportunity to resubmit copies of any evidence he may have had in his possession. As of this time, he has not done so. 1. Entitlement to service connection for hemorrhoids is remanded. The appellant contends that his hemorrhoids are related to or began during his active service. Alternatively, he has asserted that his hemorrhoids began after his separation from active service, and are due to gastrointestinal issues caused by his service-connected PTSD. See Appellant's April 2016 Statement in Support of Claim. While the Board regrets further delay in rendering a decision on this claim, after a review of the evidence of record, the Board finds that further development is necessary prior to adjudicating this claim. A VA examination of the appellant's hemorrhoids was performed in April 2021. At that examination, the appellant was diagnosed with internal and external hemorrhoids. He reported an onset of symptoms sometime around 2000, after active duty. He indicated that he believed they were brought about by chronic irritable bowel syndrome and constipation, which he attributes to his service-connected PTSD. After reviewing the evidence of record and completing the examination, the examiner opined that the appellant's hemorrhoids were not at least as likely as not directly related to or incurred during his period of active service. The examiner reasoned that in-service treatment records did not show any evidence or complaints of hemorrhoids, that the appellant asserted an onset of symptoms in around 2000, many years after his separation from active service, and because diagnostic testing confirming the diagnosis did not occur until 2004. The examiner did note that the appellant had raised a contention of secondary service connection, but failed to offer an opinion on that theory of entitlement. In August 2021, VA obtained an addendum medical opinion which determined it was less likely than not that the appellant's hemorrhoids were proximately due to or aggravated beyond their natural progression by his service-connected PTSD. The examiner reasoned that "there is no physiologic or anatomic mechanism by which PTSD and related psychological comorbidities can cause or aggravate hemorrhoids or anal fissures." In support of this conclusory statement, the examiner offered that "[t]his is established medical knowledge or practice." After review, the Board finds that the August 2021 VA medical opinion rationale is inadequate. The Board notes that the examiner did not provide an adequate explanation, merely making a general statement that "medical knowledge or practice" establishes that the opinion is correct. The Board notes that the probative value of a VA medical opinion comes from its reasoning. See Nieves - Rodriguez v. Peake, 22 Vet. App. 295 (U.S. 2008). As no reasoned explanation was offered for the medical opinion, the Board finds that the opinion has no value and is inadequate. Additionally, it does not appear that the August 2021 VA medical opinion gave adequate consideration to the appellant's theory of entitlement. The examiner opined there was no "physiologic or anatomic mechanism" by which a psychiatric disability might cause hemorrhoids or anal fissures. This seems to the Board to imply that the examiner did not consider the appellant's contention regarding an intermediate cause. See VAOPGCPREC 1-2017 (Jan. 6, 2017). The appellant's contention is not that having a mental illness somehow, in and of itself, caused him to develop hemorrhoids and anal fissures, but rather, he contends that these mental health symptoms, such as depressed mood and anxiety, caused him to develop gastrointestinal issues, that in turn, proximately caused the development of his hemorrhoids. Instead, it seems the examiner limited the opinion to consideration of whether having a mental health disability directly leads to hemorrhoids, without consideration of the direct symptoms of a mental health disability and additional unrelated symptoms that might arise. As such, the Board finds that an additional VA examination is warranted to determine whether the appellant's hemorrhoids and anal fissures are proximately due to, or aggravated beyond their natural progression by, his service-connected PTSD, to include by way of an intermediary step of gastrointestinal issues proximately due to or aggravated beyond their natural progression by his service-connected PTSD and its symptoms. Therefore, the claim is remanded so that the RO can obtain an adequate addendum medical opinion. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the appellant's hemorrhoids with anal fissures are at least as likely as not proximately due to his service-connected posttraumatic stress disorder or are aggravated beyond their natural progression by service-connected disability. In rendering such an opinion, the examiner must discuss and address the appellant's theory of entitlement regarding gastrointestinal symptoms such as IBS or constipation being an intermediary step between his service-connected PTSD and symptoms and his hemorrhoids. To put it another way, does the appellant's service-connected PTSD at least as likely as not proximately cause, or aggravate beyond its normal progress, any gastrointestinal issues, which in turn, proximately cause or aggravate beyond their natural progress the appellant's hemorrhoids with anal fissures? For reference, the examiner is advised that the VA's Office of General Counsel opinion 1-2017 held that a condition may act as an "intermediate step" between a service-connected disability and a current disability. See VAOPGCPREC 1-2017 (Jan. 6, 2017). In those cases, service connection on a secondary basis or on a basis of aggravation would still be warranted if the evidence at least as likely as not showed that the service-connected disability was the proximate cause of the intermediary step which in turn was at least as likely as not the proximate cause of the claimed disability. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Kleponis 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.