Citation Nr: 21065905 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 12-17 487A DATE: October 27, 2021 REMANDED Entitlement to service connection for uterine fibroids with painful menstruation, abdominal hysterectomy, and residual abdominal scar, claimed as an undiagnosed illness, is remanded. Entitlement to service connection for a miscarriage, claimed as an undiagnosed illness and as secondary to uterine fibroids with painful menstruation, abdominal hysterectomy, and residual abdominal scar, is remanded. Entitlement to service connection for anemia, claimed as an undiagnosed illness and as secondary to uterine fibroids with painful menstruation, abdominal hysterectomy, and residual abdominal scar, is remanded. Entitlement to service connection for fibromyalgia, body and muscle aches, and fatigue, claimed as an undiagnosed illness, is remanded. Entitlement to an initial compensable rating higher for a bilateral eye disability is remanded. Entitlement to a rating higher than 10 percent for frostbite residuals in the right foot is remanded. Entitlement to a rating higher than 10 percent for frostbite residuals in the left foot is remanded. Entitlement to a rating higher than 10 percent for frostbite residuals in the right hand is remanded. Entitlement to a rating higher than 10 percent for frostbite residuals in the left hand is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1984 to February 1987, and November 1988 to December 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2011 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). In February 2017, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript is of record. In September 2017 and January 2021, the Board remanded the case for further development. 1. Entitlement to service connection for uterine fibroids with painful menstruation, abdominal hysterectomy, and residual abdominal scar, claimed as an undiagnosed illness, is remanded. The Veteran testified that painful menstruation began during service. Her cysts started during service, and they were discovered a few years after separation. The cysts led to the hysterectomy. Hearing transcript, p. 19-20. The January 2021 Board remand instructed the examiner to provide an opinion on the etiology of that any uterine fibroids and current residuals of hysterectomy. At the April 2021 VA examination, the Veteran reported mild intermittent pain. She had a hysterectomy in 2009 due to fibroids. The examiner did not address whether there was a current diagnosis for fibroids or diagnosis during the appeal period. Further, the examiner's opinions did not respond to whether the Veteran's fibroids were related to in-service complaints. Instead, the examiner found that intense pain and heavy bleeding during service could not be directly correlated to causing a hysterectomy. The April 2021 opinion applied the incorrect standard of law. The standard is at least as likely as not, which means more than 50 percent. For these reasons, the Board finds the April 2021 opinions are incomplete. On remand, the Board finds an additional opinion is necessary. 2. Entitlement to service connection for a miscarriage, claimed as an undiagnosed illness and as secondary to uterine fibroids with painful menstruation, abdominal hysterectomy, and residual abdominal scar, is remanded. The claim for service connection for miscarriage is inextricably intertwined with the claim for service connection uterine fibroids. The April 2021 examiner found no diagnosis for uterine fibroids. As the examiner did not provide a response on whether there was a current diagnosis during the appeal period and the claim for service connection uterine fibroids is being remanded, the Board finds the claim for service connection for miscarriage must be deferred. Where a claim is inextricably intertwined with another claim, the claims must be adjudicated together. Harris v. Derwinski, 1 Vet. App. 180 (1991). Therefore, further consideration of the claim for service connection for miscarriage must be deferred. 3. Entitlement to service connection for anemia, claimed as an undiagnosed illness and as secondary to uterine fibroids with painful menstruation, abdominal hysterectomy, and residual abdominal scar, is remanded. The Veteran reported that she was diagnosed with anemia when she was pregnant during service. Hearing transcript, p. 29-31. In the January 2021 remand, the Board requested an opinion on whether any anemia that the Veteran had its onset during service and to consider the Veteran's lay statements. In addition, the examiner was instructed address whether any anemia was caused or aggravated uterine fibroids or current residuals of a hysterectomy. The April 2021 VA examination showed a current diagnosis and she reported continued symptomatology since service. The April 2021 VA examiner provided a negative opinion for direct service connection because there was no evidence to show a diagnosis during service. Further, the examiner stated that uterine fibroids or residuals of hysterectomy would not lead to chronic anemia. However, no rationale was provided for this statement. The April 2021 opinions did not take the Veteran's lay statements into consideration. For these reasons, the Board finds the April 2021 opinions are incomplete. On remand, the Board finds an additional opinion is necessary. 4. Entitlement to service connection for fibromyalgia, body and muscle aches, and fatigue, claimed as an undiagnosed illness, is remanded. The Veteran contends that her disability that is manifested by body and muscle aches, and fatigue began during service. Hearing transcript, p. 40-41. The January 2021 Board remand instructed the examiner to provide an opinion on the etiologies of the reported body aches, muscle aches, and fatigue. In addition, the Board requested an opinion on whether the symptoms were attributable to known clinical diagnoses. The examiner was directed to state if a disease or disability causing the reported symptoms could not be identified. The April 2021 opinion provided a negative nexus because there was no pathology or diagnosis to render an opinion. The accompanying examination report showed the Veteran reported that her symptoms had improved. However, the examiner did not address the symptomatology that has been consistently reported during the appeal period. As the Veteran may not experience those symptoms at a particular examination, the Board requests an opinion be rendered regarding the reported symptoms to account for whether those symptoms are episodic in nature as they were present during the appeal period. For these reasons, the Board finds the April 2021 opinion is incomplete. On remand, the Board finds an additional opinion is necessary. 5. Entitlement to an initial compensable rating higher for a bilateral eye disability is remanded. The January 2021 Board remand instructed the examiner to provide opinions on additional eye diagnoses in the record. In an April 2021 opinion, the examiner opined the blepharitis was not aggravated by the service-connected dry eyes, but instead due to one of five etiologies. Further, the conjunctivitis was also not due to the service-connected dry eyes, but instead due to allergies, virus, or bacteria. After these opinions were rendered, the Veteran was granted service connection for two of the possible etiologies, including allergies, and dermatitis. In addition, the Board notes the rating criteria was updated in May 2018 after the Veteran's most recent VA examination in February 2018. As the examiner did not have the opportunity to address these additional service-connected disabilities, the Board finds an opinion is necessary following an updated examination. 6. Entitlement to a rating higher than 10 percent for frostbite residuals in the right foot is remanded. 7. Entitlement to a rating higher than 10 percent for frostbite residuals in the left foot is remanded. At the February 2018 VA skin examination, the Veteran reported that her toenails would flake and had come off in past since the frostbite incident. The Board notes the examiner did not address the Veteran's reported toenail flaking and falling off. As these symptoms indicate a potential worsening, the Board finds it necessary to remand this matter to afford the Veteran an opportunity to undergo an additional VA examination. Snuffer v. Gober, 10 Vet. App. 400 (1997). 8. Entitlement to a rating higher than 10 percent for frostbite residuals in the right hand is remanded. 9. Entitlement to a rating higher than 10 percent for frostbite residuals in the left hand is remanded. At the February 2018 VA cold injury residuals examination, the Veteran reported that her fingernails would always peel. She used cream on her fingertips. The examiner did not provide any response to whether the Veteran had any signs or symptoms present for the bilateral hand cold injury residuals. Further, the examiner did not address the Veteran's reported fingernail peeling. When obtains an evaluation, the evaluation must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Because of the cited deficiency in the February 2018 examination report, the Board finds that further VA cold injury residuals evaluation is necessary. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from December 2020 to the present. 2. Obtain an opinion from an appropriate clinician to determine the nature and etiology of that any uterine fibroids and current residuals of hysterectomy. The Veteran's claims file and a copy of this remand must be provided to the examiner for review, and the examination reports should reflect review of these items. The examiner must opine on to whether it is at least as likely as not (50 percent probability or greater) that any uterine fibroids and current residuals of hysterectomy (diagnosed during the appeal period) are related to an in-service injury, event, or disease, to include serving in the Persian Gulf region and reports of menstrual irregularities during service. The examiner must accept the Veteran's reports of in-service menstruation symptomatology as credible. A complete rationale for all opinions expressed should be clearly provided. 3. Obtain an opinion from an appropriate clinician to determine the nature and etiology of the anemia. The Veteran's claims file and a copy of this remand must be provided to the examiner for review, and the examination reports should reflect review of these items. 4. The examiner must opine on to whether it is at least as likely as not (50 percent probability or greater) that the anemia is related to an in-service injury, event, or disease, to include serving in the Persian Gulf region. The examiner should also opine whether it is at least as likely as not (50 percent probability or greater) that the anemia was caused by the uterine fibroids or current residuals of a hysterectomy. The examiner should further opine as to whether it is at least as likely as not (50 percent probability or greater) that the anemia has been aggravated (increased in severity beyond the natural progress of the disorder) by uterine fibroids or current residuals of a hysterectomy. The examiner must consider the Veteran's statements and all lay statements regarding onset in-service and statements regarding the continuity of symptomatology. A complete rationale for all opinions expressed should be clearly provided. 5. Obtain an opinion from an appropriate clinician to determine the etiology of the disability manifested by body and muscle aches, and fatigue should be obtained. The Veteran's claims file and a copy of this remand must be provided to the examiner for review, and the examination reports should reflect review of these items. (a.) Identify any current body and muscle aches, and fatigue and/or fibromyalgia disability and fully describe the extent and severity of those symptoms. The examiner should elicit information about the nature of the disability and all symptoms or manifestations of the disability when present, even if not present at the time of the examination, including body and muscle aches, and fatigue. (b.) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that such body and muscle aches, and fatigue or fibromyalgia disability arose during service or are otherwise related to any incident of service, to include serving in the Persian Gulf region. (c.) If the examiner finds no clinical diagnosis of any body and muscle aches, and fatigue or fibromyalgia disability that was incurred in, caused by, or otherwise related to the Veteran's active military service, the examiner should provide an opinion as to whether the Veteran exhibits objective indications of an unexplained, chronic multisymptom illness due to an undiagnosed illness as defined under 38 C.F.R. §3.317. For purposes of 38C.F.R. §3. 317 "objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. All opinions expressed by the examiner must be accompanied by a complete rationale. 6. Schedule the Veteran for a VA eye examination to determine the current severity of the Veteran's service-connected eye disability. The examiner must review the claims file and should note that review in the report. Any and all studies or tests deemed necessary should be performed. The examiner should describe the nature and severity of all manifestations of the Veteran's eye disability. The examiner should elicit information about the nature of the eye disability and all symptoms or manifestations of the disability when present, even if not present at the time of the examination, including dry eyes and redness. The examiner should also comment on the functional impairment resulting from the Veteran's eye disability. The examiner should state all examination findings, with the rationale for the comments and opinions expressed. If for any reason the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should provide information to allow application of all applicable rating criteria during the appeal period, including the versions of the eye rating criteria effective prior to and as of May 13, 2018. The examiner is advised that, prior to May 13, 2018, an incapacitating episode is defined as a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare professional. As of May 13, 2018, an incapacitating episode is defined as an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. Following the examination and a review of the record, the examiner must provide the following: (a.) Is it at least as likely as not (50/50 probability or greater) that the Veteran's blepharitis (as documented in August 2011) began during or is otherwise related to service? (b.) Is it at least as likely as not (50/50 probability or greater) that the Veteran's blepharitis (as documented in August 2011) is due to or aggravated by her service-connected disabilities, including allergies and dermatitis? (c.) Is it at least as likely as not (50/50 probability or greater) that the Veteran's conjunctivitis (as documented in August 2011) began during or is otherwise related to service? (d.) Is it at least as likely as not (50/50 probability or greater) that the Veteran's conjunctivitis is due to or aggravated by her service-connected disabilities, including allergies and dermatitis? 7. Schedule the Veteran for a VA examination to determine the current severity of her service-connected bilateral hand and feet frostbite residuals. The examiner must review the record and must note that review in the report. All necessary tests should be performed, and the results reported. All pertinent symptomatology and findings must be reported in detail. The examiner should elicit information about the nature of the bilateral hand and feet cold injury residuals and all symptoms or manifestations of the disability when present, even if not present at the time of the examination, including fingernail and toenail flaking, and toenails falling off. A complete rationale for all opinions expressed should be clearly provided. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Kass, 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.