Citation Nr: 21062645 Decision Date: 10/08/21 Archive Date: 10/08/21 DOCKET NO. 18-36 136 DATE: October 8, 2021 REMANDED Entitlement to service connection for rheumatoid arthritis of multiple joints is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from April 2012 to March 2013, with additional service in the Army National Guard. He received the Afghanistan Campaign Medal with Campaign Star, Army Commendation Medal, and Army Achievement Medal, among other decorations. The Board sincerely thanks the Veteran for his honorable military service. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a rating decision issued by the Department of Veterans Affairs (VA). The Veteran testified before the undersigned Veterans Law Judge in July 2021. A transcript of the hearing is associated with the claims file. 1. Entitlement to service connection for rheumatoid arthritis of multiple joints The Board finds that this matter must be remanded for a clarifying medical opinion, including addressing a reasonably raised theory of entitlement to service connection on a presumptive basis for arthritis occurring within one year of the Veteran's discharge from active duty. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.309(a); Myers v. Derwinski, 1 Vet. App. 127, 130 (1991). The Veteran asserts that his rheumatoid arthritis of multiple joints had onset during or within one year of military service. See Hearing Transcript, July 2021. Service treatment records show that the Veteran reported left wrist pain and bilateral knee pain during and immediately following his active duty deployment to Afghanistan. See STR, April 2017 (p.27: showing reports in November 2012 of left wrist pain lasting for four months); STR, April 2017 (p.71: documenting left wrist and bilateral knee pain in a February 2013 post-deployment questionnaire). The record reflects VA medical opinions from Dr. B.G. in July 2017 and September 2017. In the former, Dr. B.G. limited her discussion to the Veteran's knees and did not address whether the Veteran's whole body rheumatoid arthritis had its onset during or is related to service. In the latter, she explained that she was unable to clarify whether there was a nexus to an environmental exposure during service beyond a less likely than not opinion without a specific exposure event that the Veteran experienced during military service. She further stated that the medical records "remained silent" as to whether his rheumatoid arthritis was related to an exposure event during military service. The above opinions do not address a theory of presumptive service connection for arthritis having onset within a year of active service. See 38 C.F.R. §§ 3.307(a)(3); 3.309(a) (providing that service connection may be granted on a presumptive basis for arthritis if it should manifest to a compensable degree within one year of a veteran's separation from active duty service). Furthermore, they do not address service connection on a direct basis between the Veteran's reports of left wrist pain during service and his current rheumatoid arthritis. An addendum medical opinion is necessary. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA provides a medical opinion it must be adequate for decisional purposes). The Board observes that the Veteran did not serve in the Southwest Asia theater of operations as defined by applicable regulations. See 38 C.F.R. § 3.317(e)(2) (defining the Southwest Asia theater of operations as "Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations"). Moreover, the medical evidence does not support the existence of an undiagnosed illness or medically unexplained chronic multi-symptom illness. His symptoms have been attributed to rheumatoid arthritis which is a diagnosed medical condition. Nevertheless, the Veteran asserted that his rheumatoid arthritis could be related to "environmental exposures". He did not specify which exposures he believed could have caused his rheumatoid arthritis. The Board is unable to consider such a broad theory of entitlement without specific allegations that an identified exposure led to his rheumatoid arthritis. See e.g. Gobber v. Derwinski, 2 Vet. App. 470, 472 (1992) (the "duty to assist" is not a license for a "fishing expedition" to determine if there might be some unspecified information which could possibly support a claim). If the Veteran has lay or medical evidence of a specific exposure event during his military service that he believes caused or contributed to the onset of his rheumatoid arthritis, he is encouraged to provide that information to VA so that a medical opinion addressing such theory may be obtained. 38 U.S.C. § 5107(a). This matter is REMANDED for the following actions: 1. Secure for the record copies of complete updated clinical records of all VA and non-VA treatment the Veteran has received for the disorder on appeal. 2. Provide the Veteran with an opportunity to submit additional information regarding his asserted exposures to environmental contaminants in Afghanistan during active duty service. Document all development associated with this directive in the claims file. 3. Obtain a clarifying medical opinion discussing the nature and etiology of the Veteran's rheumatoid arthritis of multiple joints. The clinician is asked to review the claims file and to opine on the following: (a) Is it at least as likely as not that the Veteran's rheumatoid arthritis had its onset during or is causally related to military service, to include the reports of recurrent left wrist pain and bilateral knee pain? (b) Is it at least as likely as not that the Veteran's rheumatoid arthritis had its onset as a chronic disease entity to a compensable degree within one year of the Veteran's separation from active duty service? (c) If, and only if, specific information on the Veteran's environmental exposures has been received, is it at least as likely as not that the Veteran's rheumatoid arthritis is causally related to an identified environmental exposure during active duty service? A complete rationale should be provided for all opinions. The clinician is asked to consider and discuss relevant lay and medical evidence, to specifically include: Letter submitted by S.J., physician's assistant, dated May 4, 2021 Private medical records from St. Luke's Hospital from February 2013 to March 2016 Private medical records from Arthritis Northwest PLLC, the Kootenai Clinic, and Covance CLS received in December 2016 Service treatment records reflecting complaints of recurrent left wrist pain and bilateral knee pain, including post-deployment health assessment in February 2013 documenting a history of left wrist and bilateral knee pain, and continued profiles for knee and wrist pain in March and September 2013 The Veteran's lay contentions that he was suffering from undiagnosed rheumatoid arthritis while on active duty service, per his complaints of left wrist and bilateral knee pain during and after service The clinician is reminded that the term "at least as likely as not," does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the clinician's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Reed, 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.