Citation Nr: 21066844 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 17-32 802 DATE: November 2, 2021 REMANDED The issue of service connection for Gulf War syndrome is remanded. REASONS FOR REMAND The Veteran had active duty in the United States Army Reserve from November 1990 to May 1991 with service in Southwest Asia from December 1990 to April 1991. This matter comes before the Board of Veterans' Appeals (Board) from an August 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) which denied, in pertinent part, service connection for gulf war syndrome (GWS) with a series of chronic unrelated illnesses. The Veteran submitted a Notice of Disagreement (NOD) in September 2013 and a Statement of the Case (SOC) was issued in April 2017. The Veteran perfected an appeal by submitting a timely VA Form 9 in June 2017. The issue was previously before the Board. In May 2020, the Board remanded the appeal to the agency of original jurisdiction (AOJ) for additional development. Specifically, the Board directed the AOJ to obtain any outstanding VA Medical Center treatment records since September 2018; to schedule the Veteran for a VA examination to determine the nature and etiologies for his claimed gastroesophageal reflux disease (GERD) and chronic unrelated illnesses to include blisters, swelling, bruising of the leg, and chronic joint pain; and to obtain medical opinions on the etiologies of the above claims and to determine if any of his symptoms was an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) as established by history, physical examination, and laboratory tests. In August 2020, the AOJ added the Veteran's VA Medical Center treatment records from July 2013 to August 2020. The Veteran was also afforded a VA examination for his claims in the same month. An addendum medical opinion was added addressing the etiologies of the claimed disabilities and symptoms, as well as opining that the Veteran's symptoms were related to an undiagnosed illness. 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). "Gulf War syndrome" is not a single disability but rather a term for a number of certain chronic unexplained illnesses both diagnosed and undiagnosed. 38 C.F.R. § 3.117 (2020). The Veteran was previously awarded service connection for irritable bowel syndrome and fibromyalgia, both associated with service in the Persian Gulf. Before the matter was certified to the Board, in a September 2020 rating decision, the RO granted service connection for GERD and assigned an initial 30 percent rating, effective April 24, 2017. The award of service connection constitutes a complete grant of the benefit sought on appeal. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of downstream elements such as the disability rating or effective date assigned). The Veteran was in receipt of a combined 80 percent rating from November 30, 2016 and a temporary 100 percent rating from October 19, 2017 to November 30, 2017. Currently, the Veteran is in receipt of a combined 90 percent rating from December 1, 2017. A supplemental statement of the case (SSOC) was issued in September 2020 denying the claim of service connection for gulf war syndrome with a series of chronic unexplained illnesses other than those already found to be service-connected. The Veteran appeared at a February 2020 videoconference hearing before a Veterans Law Judge. The hearing transcript is of record. In September 2021, the Veteran was notified that the Veterans Law Judge who conducted the February 2020 hearing had retired. The Veteran was also notified that he had the right to another Board hearing and to respond within 30 days if he wanted another hearing. The Veteran did not respond within 30 days and thus the Board finds that the Veteran did not wish another hearing. Service connection for Gulf War syndrome The Veteran contends that he has had unexplained blisters, severe swelling, bruising of the legs, and chronic joint pain during or shortly since his service in Southwest Asia. In September 2020, a VA examiner opined that "there was no evidence" that the Veteran's reported symptoms were related to exposures during his deployment to Southwest Asia. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006) (holding that the Board cannot determine that lay evidence as to diagnosis and nexus lacks credibility merely because it is unaccompanied by contemporaneous medical evidence). The examiner, other than citing the lack of documented evidence, did not offer a rationale for her opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("most of the probative value of a medical opinion comes from its reasoning"); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Moreover, she opined, ambiguously and contrary to her previous opinion, that the Veteran's symptoms were "related to an undiagnosed illness" without discussing reports by the Veteran that he was diagnosed as having athlete's foot when he complained of blisters in his foot or discussed whether these symptoms have existed for 6 months or more, and/or exhibited intermittent episodes of improvement and worsening over a 6-month period. She also stated that "exposures while in Southwest Asia has not been determined as being the cause of the Veteran's symptoms," again without rationale. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. Here, despite opining earlier that the Veteran's symptoms were not related to his exposure in Southwest Asia, the September 2020 VA examiner opined that the symptoms were, indeed, related to "an undiagnosed illness." McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121 (1991). When VA obtains an evaluation, the evaluation must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The matter is REMANDED for the following action: Obtain an addendum VA medical opinion regarding the Veteran's symptoms of blisters, severe swelling and bruising of the legs, and chronic joint pain (other than symptoms associated with fibromyalgia). Specifically, the examiner must opine: (a.) Whether it is at least as likely as not (50 percent or greater probability) that blisters, severe swelling and bruising of the legs, and chronic joint pain can be ascribed to any known clinical diagnoses, to include athlete's foot as reported by the Veteran on January 30, 2020, or his other diagnosed disabilities. As to each diagnosed disorder, the examiner should render an opinion as to whether it is at least as likely as not that any such disorder had its onset during any period of the Veteran's active duty service, or if each diagnosis is otherwise related to such service, to include as due to environmental exposures in Southwest Asia. (b.) If any of the Veteran's symptoms cannot be ascribed to any known clinical diagnosis, then the VA examiner should specify as to whether each, that is blisters, severe swelling and bruising of the legs, and chronic joint pain, is an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) as established by history, physical examination, and laboratory tests, that have either (i) existed for 6 months or more, or (ii) exhibited intermittent episodes of improvement and worsening over a 6-month period. The VA examiner should address the Veteran's competent reports that he has experienced blisters, bruises, swelling and pain since separating from service, as well as his statements in the VA Medical Center treatment records such as his January 2020 statement of his dermatologist attributing his blisters to athlete's foot. A rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. 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.