Citation Nr: 21070701 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 17-54 164 DATE: November 24, 2021 REMANDED Entitlement to service connection for vertigo and/or Meniere's disease (claimed as dizziness) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from February 1985 to July 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In April 2019, the Board issued a decision that, in relevant part, denied the Veteran's claim for service connection for dizziness. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court), and in a January 2020 Order, the Court vacated the portion of the April 2019 Board decision denying service connection for dizziness, and remanded the matter to the Board for action consistent with the Joint Motion for Partial Remand. The Board remanded the appeal for further development in July 2020. It has since been returned to the Board for further appellate review. Entitlement to service connection for vertigo and/or Meniere's disease (claimed as dizziness) is remanded. While the Board regrets any further delay, remand is again found warranted in order for VA to meet its duty to assist the Veteran in pursuit of his claim. The evidence of record indicates that treatment records relevant to the claim may remain outstanding. Specifically, at the September 2020 VA examination, the Veteran reported receiving treatment for traumatic brain injury, including acupuncture, diet/exercise, and therapy sessions. On remand, the Agency of Original Jurisdiction should contact the Veteran to request that he identify and if necessary, provide appropriate authorization for VA to obtain private records of such treatment on his behalf. VA treatment records additionally document that the Veteran suffered a severe vertigo spell leading to a fall and concussion in October 2017. The claims file includes non-VA emergency care notes indicating that documents from October 22, 2017 had been scanned into VistA Imaging. Unfortunately, the Board does not have access to VistA Imaging and is therefore unable to review these documents. On remand, such documents should be added to the Veteran's electronic claims file. Pursuant to the Board's July 2020 remand instructions, the Veteran was provided with a VA examination. The September 2020 examination report indicates current diagnoses of Meniere's syndrome and tympanic membrane scar, and documents the Veteran's reports of close proximity to IED blasts in 1985. The Veteran further reported treatment for traumatic brain injury including acupuncture, diet/exercise, and therapy sessions. The examiner stated an opinion that it is at least as likely as not that the Veteran's Meniere's disease was caused during a service injury. As reasoning, she stated that the Veteran was diagnosed with vertigo/chronic sinusitis in an optometry note in March 2016, was diagnosed with Meniere's disease by a Dr. B.F. in June 2018, and was diagnosed with Meniere's disease related to an in-service traumatic brain injury including concussion by a Dr. S.C.. An additional VA opinion was provided in September 2021, that it was less likely than not that the Veteran's Meniere's disease is related to an in-service injury, event, or disease. The physician who provided the opinion stated that there is no objective evidence of related complaints or treatment having occurred during service, and no evidence of a prior traumatic brain injury, and therefore, the current condition is likely to represent a separate and discrete disease process. Neither of the opinions provided is found to be adequate for adjudicatory purposes, as the rationales provided for the stated conclusions are found lacking. With regard to the September 2020 report, the conclusions and opinion stated appear to be based on the Veteran's unsupported lay statements (including those made to prior treating providers), of suffering a traumatic brain injury in service, then receiving a diagnosis of Meniere's disease. Review of the treatment records, however, demonstrates that the June 2018 record (referenced as a diagnosis of Meniere's disease by Dr. B.F. in the examination report) is rather a secure message from the Veteran to the primary care physician stating that he had Meniere's disease, and the August 2016 record referencing diagnosis by Dr. S.C. indicates that the Veteran reported that he was told by an ENT that he has Meniere's disease. An earlier March 2016 otolaryngology consult note assessment indicates that the Veteran's reported symptoms are "possibly related to Meniere's disease, however not all symptoms are consistent." VA medical examination and opinion was sought in part to determine whether the Veteran actually suffers from Meniere's disease; it is unclear from the report whether the diagnosis rendered in September 2020 was based on objective findings at the time of the examination and/or consideration of prior test results or merely on the notations made by prior treatment providers. Throughout the appeal period, the Veteran has consistently asserted (and reported to his treatment providers) that the severity and frequency of his vertigo symptoms increase with stress and during panic attacks. The Veteran has been granted service connection for posttraumatic stress disorder. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for vertigo/dizziness because no medical opinion has been provided as to whether such is proximately caused or aggravated by his service-connected PTSD. On remand, a supplemental medical opinion should be provided on this theory of entitlement. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from July 2020 to the present and associate them with the electronic claims file. To the extent that there are relevant non-VA treatment records that have been scanned into VA systems (such as Vista Imaging) during the relevant appeal period, such should be added to the record [this includes, but is not limited to the October 22, 2017 non-VA care emergency notes pertaining to the Veteran's vertigo and resulting fall injuries]. 2. Ask the Veteran to adequately identify and complete a VA Form 21-4142 for any relevant private treatment records he wishes for VA to obtain on his behalf, to include those pertaining to acupuncture and therapy sessions for TBI referenced in the September 2020 VA examination report. Make two requests for the authorized records, unless it is clear after the first request that a second request would be futile. 3. After associating all records responsive to the above with the claims file, refer the file to a suitably-qualified medical professional ("clinician") for a supplemental medical opinion concerning the nature and etiology of the Veteran's claimed dizziness/vertigo. The clinician must review the claims file. If additional examination is deemed necessary in order to respond to the below inquiries, such should be scheduled and the Veteran provided with appropriate notice. The clinician is asked to address the following: a. Identify a diagnosis for any disability resulting in dizziness present at any time during the relevant appeal period (March 2016 to the Present); the clinician is asked to specifically confirm or rule out diagnoses of vertigo, Meniere's disease, and traumatic brain injury. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms, such as dizziness/vertigo, that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. In responding to this question, the clinician should discuss both the lay and medical evidence considered, including results of diagnostic testing. b. For any relevant disability manifesting in dizziness/vertigo identified, is it at least as likely as not (50 percent or greater probability) related to an in-service injury, event, or disease? In responding to this question, the clinician's attention is directed to the following: The Veteran's lay reports of being in close proximity to two IED explosions in 1985, and experiencing head pain, dizziness, ringing ears, decreased hearing for several days, and bleeding from his ears; The Veteran's lay reports of experiencing vertigo in service and intermittently since service; The Veteran's report of medical history at his May 1992 separation examination denying then or ever having dizziness or fainting spells, ear, nose, or throat trouble, hearing loss, head injury, or periods of unconsciousness. c. For any relevant disability manifesting in dizziness/vertigo identified, is it at least as likely as not proximately caused by the Veteran's service-connected PTSD? d. For any relevant disability manifesting in dizziness/vertigo identified, is it at least as likely as not aggravated beyond its natural progression by the Veteran's service-connected PTSD? In responding to subparts c & d, the clinician's attention is directed to the Veteran's lay reports to physicians throughout the appeal period that his episodes of vertigo and nausea occur more frequently when stressed, and his report documented in a July 2013 H&P note that his ENT doctor said they did not see anything with his inner ear that would cause the episodes, so the conclusion was that it is due to stress. The clinician must provide a rationale to support any opinion stated. In providing the requested opinion, consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 4. After completing the above, and conducting any further development deemed necessary in light of the expanded record, readjudicate the claim for service connection for disability manifesting in vertigo/dizziness. If the benefits sought remain denied, issue the Veteran and his representative a supplemental statement of the case and allow them an opportunity to respond before returning the appeal to the Board. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Solomon, 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.