Citation Nr: 21070287 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 16-63 961 DATE: November 23, 2021 REMANDED Service connection for muscle pain, to include as due to undiagnosed illness or other qualifying chronic disability pursuant to 38 C.F.R. § 3.317, is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1977 to April 1981 and February 1991 to June 1991. In June 2019, the Veteran and his wife testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. A November 2020 Board decision, in pertinent part, denied service connection for muscle pain, to include as due to undiagnosed illness or other qualifying chronic disability pursuant to 38 C.F.R. § 3.317. The Veteran appealed the decision to the U.S. Court of Appeals for Veterans Claims (Court). In August 2021, the Court issued an order that vacated the Board decision and remanded the matter on appeal for adjudication consistent with the Joint Motion for Partial Remand (JMPR). Service connection for muscle pain The August 2021 JMPR found the Board erred by not complying with the duty to assist in providing an adequate medical opinion. Specifically, the December 2019 VA examiner did not explain why the Veteran's muscle condition was not related to environmental exposures in Southwest Asia or whether the symptoms were indicative of an undiagnosed illness. The Board requests an addendum medical opinion to address the nature and etiology of his claimed muscle pain. The matters are REMANDED for the following action: Schedule the Veteran for an examination to determine the nature and etiology of his claimed muscle pain. The examiner should conduct appropriate diagnostic testing. The examiner should record all noted signs and reported symptoms, document all clinical findings, and provide a diagnosis if possible. The examiner must provide responses to the following: A) Identify the objective indications of the Veteran's claimed muscle pain. "Objective indications" of a qualifying chronic disability include both objective evidence perceptible to an examining physician and other non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Non-medical indicators include evidence such as time lost form work, the veteran having sought treatment for his symptoms, and change in the veteran's appearance, physical abilities, and mental or emotional attitude. 60 Fed. Reg. 6661, 6663 (Feb. 3, 1995). B) By history, physical examination, or laboratory testing, can the objective indications be attributed to a known clinical diagnosis? If the signs and symptoms are not characteristic of a known clinical diagnosis, the examiner should so indicate. There is no requirement that the examiner provide a diagnosis of undiagnosed illness. C) If the objective indications cannot be attributed to a known clinical diagnosis, is there affirmative evidence that the undiagnosed illness was not incurred during active service during the Persian Gulf War or that it was caused by a supervening condition or event that occurred since the Veteran's departure from service during the Persian Gulf War? The examiner should note that a positive response to this question requires affirmative evidence. The mere absence of evidence is not sufficient. D) If the objective indications can be attributed to a known clinical diagnosis, is the etiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood? This determination as to each must be based on the Veteran's specific case and cannot be based on the pathophysiology of the disease or disability population as a whole. (Continued on the next page) E) If both the etiology and pathophysiology are partially understood or fully understood, then is it at least as likely as not (50 percent or greater probability) the diagnosed condition was incurred in or is otherwise related to active service? A complete rationale must be provided for all opinions expressed. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Winkler, 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.