Citation Nr: 21070116 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 16-50 512 DATE: November 23, 2021 ORDER Entitlement to service connection for rheumatoid arthritis is granted. Entitlement to service connection for Sjögren's syndrome with xerostomia is granted. REMANDED Entitlement to service connection for systemic lupus erythematosus is remanded. FINDINGS OF FACT 1. The Veteran's rheumatoid arthritis was proximately due to his service-connected fibromyalgia. 2. The Veteran's Sjögren's syndrome with xerostomia was secondary to his service-connected rheumatoid arthritis. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for rheumatoid arthritis, secondary to service-connected fibromyalgia, are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for entitlement to service connection for Sjögren's syndrome with xerostomia, secondary to service-connected rheumatoid arthritis, are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service in the United States Navy from May 1990 to June 1991. The Veteran passed away in December 2020. The Appellant in this case is the Veteran's surviving spouse, who is properly substituted for the Veteran. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In August 2021, the Board remanded the case for additional evidentiary development. The case has returned for further appellate review. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The Appellant has not raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Entitlement to service connection for rheumatoid arthritis and Sjögren's syndrome with xerostomia. The Appellant contends the Veteran's rheumatoid arthritis and Sjögren's syndrome with xerostomia were related to service. Alternatively, the Appellant contends that these disabilities are secondary to the Veteran's service-connected disabilities. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012). Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). In addition, certain diseases, such as arthritis, are presumed to have been incurred in service if manifested to a compensable degree within one year after service. When chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim for such diseases. 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence showing (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by service-connected disability. 38 C.F.R. § 3.310. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt will be granted to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. To deny a claim on the merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The Board finds the Veteran had rheumatoid arthritis that was caused by his service-connected fibromyalgia and his Sjögren's syndrome with xerostomia was causally related to his rheumatoid arthritis. Here, May 2012 VA examinations show the Veteran had a diagnosis of rheumatoid arthritis and Sjögren's syndrome with xerostomia. A June 2013 VA examination report notes the Veteran took steroid injections with Remicade infusions for his rheumatoid arthritis which helped with his fibromyalgia. A February 2014 VA medical opinion notes that there is some overlap between the Veteran's rheumatoid arthritis and fibromyalgia. The examiner indicated however, that the Veteran's symptoms could be distinguished from one another as the Veteran had joint stiffness in the hands and wrists due to his rheumatoid arthritis and his fibromyalgia was characterized by widespread musculoskeletal (whole body) pain. A November 2015 VA examination report notes the Veteran's medication regime used to treat his rheumatoid arthritis was also used to help control his fibromyalgia. Additionally, a November 2012 VA medical opinion notes the Veteran had rheumatoid arthritis with secondary Sjögren's syndrome. September 2021 VA medical opinions note that due to the absence of evidence of in-service incurrence and complaints or treatments for the disabilities immediately following service the disabilities were not related to service and there was no medical literature that supported the contention that fibromyalgia could cause or permanently aggravate rheumatoid arthritis or Sjögren's syndrome with xerostomia. The Board finds this opinion inadequate as the examiner failed to provide any rationale for the opinions reached. The Board finds the evidence, when reviewed in its totality, strongly suggest that the Veteran's fibromyalgia is related to the Veteran's rheumatoid arthritis and his Sjögren's syndrome with xerostomia was secondary to his rheumatoid arthritis as noted above. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for rheumatoid arthritis and Sjögren's syndrome with xerostomia is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102, 3.310. REASONS FOR REMAND Entitlement to service connection for systemic lupus erythematosus is remanded. Unfortunately, there has not been substantial compliance with the Board's previous remand directives regarding the issue. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). In August 2021, the Board instructed the agency of original jurisdiction (AOJ) to obtain an adequate medical opinion on the nature and etiology of the Veteran's lupus on a direct and secondary basis. The Board found that the Veteran had a diagnosis of lupus during the pendency of the appeal and the examiner was to provide an opinion based on the confirmed diagnosis of lupus found in the record. Review of the September 2021 VA medical opinion reveals this was not accomplished. The examiner noted the Veteran did not have a diagnosis of lupus and therefore it was not related to service. As the examiner failed to provide an adequate opinion based on the confirmed diagnosis of lupus, a remand is required. Additionally, this decision has granted service connection for rheumatoid arthritis and Sjögren's syndrome with xerostomia and the medical evidence indicates there may be a relationship between these disorders and the Veteran's lupus, as such an additional opinion is required. The matter is REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician to determine the nature and etiology of the Veteran's systemic lupus erythematosus. The examiner must review the claims file. THE EXAMINER MUST ACCEPT THE VETERAN HAD A CURRENT DIAGNOSIS OF LUPUS DURING THE PENDENCY OF THE CLAIM. The examiner is asked to provide a response to the following: (a.) Was the Veteran's lupus at least as likely as not related to service? (b.) Was the Veteran's lupus at least as likely as not proximately due to a service-connected disability? (c.) Was the Veteran's lupus at least as likely as not aggravated, i.e., worsened beyond its natural progression, by a service-connected disability? (d.) Was it at least as likely as not that the Veteran's lupus (1) began during active service, (2) manifested within one after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? The examiner is advised: He/she must fully explain the opinions. A summary conclusion is not sufficient under the law and the opinion will be returned for further clarification. The examiner is advised that the Veteran, during his life, was competent to report his symptoms and history, and such reports must be acknowledged and considered in formulating any opinion. 2. After completing the requested action, and any additional actions considered warranted, readjudicate the claim on appeal. If the benefit sought on appeal remains denied, the Appellant should be given a supplemental statement of the case and given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. K.A. KENNERLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. McDuffie, 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.