Citation Nr: 21068911 Decision Date: 11/15/21 Archive Date: 11/15/21 DOCKET NO. 16-57 710 DATE: November 15, 2021 REMANDED Entitlement to service connection for an autoimmune/connective tissue disorder, claimed as lupus, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1989 to February 1990 and from August 2005 to July 2007. In November 2017, the Veteran testified before the undersigned Veterans Law Judge sitting at the St. Petersburg RO. A copy of the hearing transcript is of record and has been reviewed. In December 2018, the Board remanded the Veteran's claim for further development, to include obtaining VA and private medical records and an examination and medical opinion. The case has since returned for further appellate consideration. Etiology Opinion Pursuant to the 2018 Board remand, the Veteran was provided with February 2020 VA compensation examinations. The VA examiner, a physician's assistant, opined that the Veteran does not meet the criteria for a diagnosis of SLE, per her private rheumatologist's notes. The examiner then opined that claimed lupus was less likely as not related to service. The examiner stated that leukopenia alone is not a symptom of SLE or any other connective tissue disorder. The examiner noted that the Veteran's private rheumatologist noted that the Veteran's low white count could be due to medication, and a family history of leukopenia was also noted (see 2011 treatment note showing notation of benign familial leukopenia). In a July 2020 VA addendum, a VA examiner, a physiatrist, opined that there is no evidence to support that the Veteran's autoimmune disorder, diagnosed as undifferentiated mixed connective tissue disorder (diagnosed in 2016), had its onset during or was otherwise related to it based on a review of the electronic claims file. The Board finds the 2020 VA opinions inadequate to decide the claim. The February 2020 VA examiner noted that leukopenia alone is not a symptom of a connective tissue disorder; however, the Veteran's STRs show other complaints, such as chronic joint pain, that may be relevant to the question at issue here. The July 2020 opinion was conclusory and offered little to no meaningful rationale. In view of the needed clarification, the Board finds that another opinion, preferably from a rheumatologist or physician with background in treatment of autoimmune disorders, should be obtained. A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand orders. Where the remand orders of the Board were not complied with, the Board itself errs in failing to ensure compliance. See Stegall v. West, 11 Vet. App. 268, 271 (1998). This obligation is mandatory, not discretionary. Private Medical Records The evidence shows that the Veteran is being treated by rheumatologists at both the VA and a private clinic, Watson Clinic. The private clinician, Dr. M. Ceniza, appears to be the Veteran's primary rheumatologist. See VA Rheumatology Clinic Note, dated February 14, 2018; VA Telephone Contact, dated March 27, 2020. In December 2019, the Veteran was asked to submit authorization to request treatment records from her private medical providers for her claimed lupus. However, the Veteran did not respond to the letter. Inasmuch as the Board is remanding the claim for additional opinions, the Board will provide the Veteran with an additional opportunity to submit any outstanding rheumatology records as those records are likely relevant to this claim and would aid the Board in making an informed decision based on all the evidence of record. The Veteran is reminded that the duty to assist is not a one-way street and that she is ultimately responsible for obtaining these records and submitting them to VA herself. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The matters are REMANDED for the following action: 1. Provide the Veteran with another opportunity to obtain her private rheumatology medical records. Send to the Veteran VA Form 21-2142, Authorization and Consent to Release Information to the VA, for outstanding medical records from Dr. Marian Ceniza of Watson Clinic, Lakeland, Fl, dating from 2016 to the present. Ask that she complete and return the form, and advise her that she may submit any records in her possession, if she so chooses. 2. Regardless of whether additional records are received, obtain another medical opinion preferably from a rheumatologist, with regard to the likely etiology of the Veteran's autoimmune/connective tissue disorder. After a thorough review of the claims file, particularly to include the service treatment records, the examiner must respond to the following: (a) Identify all current autoimmune/connective tissue disorders, to include undifferentiated mixed connective tissue disorder and/or lupus, diagnosed during the appellate period. (b) For each diagnosed disorder, provide an opinion as to whether it had its onset in service or is otherwise related to it. (The Veteran had two periods of active service). In doing so, clarify whether the in-service manifestations noted below were early indications of the current disorder. The examiner MUST address not only the low white blood cell counts shown in service (see May 1997, August 2006, October 2006, May 2007, and June 2007 STRs), but also: i) PEB showing chronic neck pain, thoracolumbar pain with atraumatic event during AIT in 2005, and chronic lower extremity pains with onset in 2005. ii) January 2007 failed Army retention standards; prognosis was regarded as fair due to the chronic nature of her conditions. iii) MEB including diagnoses of chronic back pain and spasms, neck strain, foot arch pain, shin splints, esophageal reflux, and Chron's. iv) May 2007 VA diagnosis of chronic pain syndrome. (c) If the current disorder is not directly related to service, provide an opinion as to whether it was proximately caused or aggravated by any of the Veteran's service-connected disabilities. A complete medical rationale for all opinions expressed must be provided. 3. Thereafter, readjudicate the remanded claim. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Beach, 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.