Citation Nr: 21062204 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 18-00 535 DATE: October 6, 2021 REMANDED Entitlement to service connection for vertigo, also claimed as dizziness is remanded. REASONS FOR REMAND The Veteran had active duty in the United States Army from March 1964 to March 1967. This matter comes before the Board of Veterans' Appeals (Board) from a May 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran submitted a Notice of Disagreement (NOD) in July 2015 and a Statement of the Case (SOC) was issued in December 2017. The Veteran perfected an appeal by submitting a timely VA Form 9 in December 2017. The issue was previously before the Board. In April 2021, the Board remanded the appeal to the agency of original jurisdiction (AOJ) for additional development. Specifically, the Board directed the AOJ to request an opinion from an appropriate clinician regarding the nature and etiology of the Veteran's vertigo and dizziness symptoms. In July 2021, the AOJ obtained a medical opinion from a VA examiner. Thus, the Board finds that the AOJ substantially complied with the remand directives and no further action is necessary in this regard. Stegall v. West, 11 Vet. App. 268 (1998). Following evidentiary development, the VA Appeals Management Center (AMC) continued the previous denials in a supplemental statement of the case (SSOC) issued in July 2021. The Veteran's VA claims file has been returned to the Board for further appellate proceedings. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.902(c). 38 U.S.C. § 7107(b). Service connection for vertigo, also claimed as dizziness In its April 2021 remand, the Board directed the clinician to take the Veteran's reports into account in formulating the requested opinion and that the Veteran was competent to report symptoms, treatment, and injuries. The Board also specifically noted an August 2005 VA treatment note indicating that the Veteran was diagnosed as having vertigo. VA Medical Center treatment records from September 2006 also show that the Veteran's past medical history included vertigo. In March 2015, the Veteran reported that he experienced an episode of sea sickness and dizziness while being transported to Korea aboard ship and that the symptoms persisted since that time. However, in a June 1967 discharge physical examination questionnaire, the Veteran denied any current or history of dizziness or car, train, sea, or air sickness and the examiner noted no related abnormalities. The July 2021 VA examiner, however, stated that there was "no treatment for vertigo listed in the C-file" despite the diagnosis of vertigo and subsequent notes of vertigo in the Veteran's past medical history in the VA Medical Center treatment records. The examiner also did not list or review the August 2005 VA treatment note in her list of relevant evidence and based her opinion, at least in part, on the lack of service treatment records for dizziness or sea sickness despite the Veteran's statements of continuing symptoms since service. Medical evidence supporting the Veteran's contention was not addressed. See Moore v. Derwinski, 1 Vet. App. 401, 404 (1991) ("the Board must include in its decisions 'the precise basis for that decision ... [and] the Board's response to the various arguments advanced by the claimant.'" (alterations in original) (quoting Gilbert, 1 Vet. App. at 53)). As the examiner omitted the prior diagnosis of vertigo, she also effectively relied upon factual inaccuracy, the opinion is inadequate, and a new examination is required to clarify the nature and etiology of the Veteran's claimed dizziness. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); see also Colvin v. Derwinski, 1 Vet. App. 171, 174 (1991) (Board may not make independent medical assessments); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"); see also Sizemore v. Principi, 18 Vet. App. 264, 271 (2004) (noting that credibility determination is not a medical matter and therefore a matter for the Board). The matter is REMANDED for the following action: 1. Obtain an addendum VA medical opinion regarding the Veteran's dizziness. The examiner should review the virtual file. The examiner is to address the following: (a.) State whether vertigo or any other disability causing the symptom of dizziness is currently present. If the examiner disagrees with a diagnosis already established in the medical records, such as the August 2005 diagnosis of vertigo or the July 2021 VA examination showing no diagnosis, he/she should so state and explain why. (b.) Whether it is at least as likely as not (50 percent or greater probability) that vertigo, or any other diagnosed disability causing dizziness, if diagnosed, manifested during or is otherwise related to the Veteran's period of active service. (c.) Whether it is at least as likely as not (50 percent or greater probability) that vertigo, or any other disability causing dizziness, if diagnosed, was caused or aggravated by service or a service-connected disability. The examiner is asked to review the March 31, 2020 VA outpatient neuropsychological evaluation and comment on and confirm or disagree with the findings of the July 2021 examiner that the symptoms may be another manifestation of his service connected mental health disorder. The examiner is advised that aggravation means any increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the clinician should attempt to quantify the degree of additional disability resulting from the aggravation. A rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered, to include the August 2005 diagnosis of vertigo and the prior July 2021 VA examination. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). The need for another examination is left to the discretion of the examiner offering the addendum opinion. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H.S. Yun, 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.