Citation Nr: 21071952 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 14-25 445A DATE: December 1, 2021 REMANDED Entitlement to service connection for a disability manifested by joint pain also claimed as arthritis of the right hip, knees, elbows, and shoulders is remanded. Entitlement to service connection for a disability manifested by muscle pain and/or neurological symptoms also claimed as restless leg syndrome and muscle spasms of the neck, back, and legs is remanded. Entitlement to service connection for a disability manifested by sleep disturbances is remanded. Entitlement to service connection for a disability manifested by fatigue is remanded. Entitlement to service connection for residuals of a head injury is remanded. Entitlement to service connection for a cardiovascular disability, to include hypertension, is remanded. Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection for a cervical spine disability is remanded. REASONS FOR REMAND The Veteran had active duty service in the Marine Corp from April 1988 to April 1993. This matter is before the Board of Veterans' Appeals (Board) following a Board Remand in May 2018. In August 2017, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Central Office hearing. A transcript of that hearing is of record. The Board is cognizant of the fact that the Veteran's case has been in adjudicative status for several years, and it has already been remanded in the past. Consequently, the Board wishes to assure the Veteran that it would not be remanding this case again unless it was essential for a full and fair adjudication of his claims. According to the former VA's Adjudication Procedures Manual which has been archived, for veterans who separated from the United States Marine Corps prior to May 1, 1994, medical and personnel records were sent to the United States Marine Corps Headquarters in Quantico, VA. Thereafter, a year after retirement or at the end of the military obligation, they are transferred to the National Personnel Records Center (NPRC). The Manual also indicates that the records of Marines who had additional reserve obligations may have gone to either the reserve unit or to the Records Management Center (RMC). The current manual indicates that if the Veteran was separated from active duty with Reserve obligation between May 1994 and December 2013, the source to obtain medical and dental records is Healthcare Artifacts and Image Management Solution (HAIMS) if inactive or not assigned to a unit or the RMC Source Material Tracking System. The file indicates that the Veteran's service treatment records were requested in June 2008 from Personnel Information Exchange System (PIES) for records stored at RMC and NPRC which is used if the Veteran separated with no Reserve obligation. In November 2010, the Veteran's service treatment records were requested from Defense Personnel Records Information Retrieval System (DPRIS) which noted that the record was found in the Service repository system but routine automated access to available digital image documents was not available and recommended contacting the Service repository action office using secure DPRIS follow-up message capability. In July 2013 and August 2013, service treatment records were again requested. A response was received in September 2013 that no service treatments records were at the RMC but that such had been flagged if found in the future. It is the Board's opinion that an additional effort should be taken to attempt to locate the Veteran's service treatment records. His DD Form 214 indicates that he had a reserve obligation until October 29, 1995. Moreover, it is does not appear that the Veteran was provided with an NA Form 13055 to complete so that additional efforts could be made to locate records from other sources in an attempt to reconstruct the lost service data. Inasmuch as it appears that additional action by VA may be fruitful in either obtaining pertinent medical information from alternative sources or documenting that any such putative record cannot be obtained, the Board determines that further development is warranted. The matters are REMANDED for the following action: 1. Arrange for exhaustive development in efforts to obtain for association with the record copies of any available service treatment records to include utilizing HAIMS. In addition, inform the Veteran that his service treatment records are presumed lost or destroyed, furnish him a copy of the National Archives (NA) Form 13055 (Request for Information Needed to Reconstruct Medical Data) and the NA Form 13075 (Questionnaire About Military Service), and ask him to complete and return the forms to VA. If the Veteran completes and returns the NA Form 13055 and NA Form 13075, as requested above, request from the Records Reconstruction Unit of the NPRC (or its equivalent source) an additional search from alternate sources of all available service treatment records, including any separately maintained clinical records; sick reports; morning reports; and any other sources. All facilities where such records may be stored should be searched. If such records have been destroyed, are irretrievably lost, and/or the search efforts of alternative sources otherwise yield negative results, it must be so certified for the record, and the Veteran should be notified. The scope of the search must be noted in the record (along with a description of the extent of the search conducted and an explanation for the negative results, e.g., record of unavailability). 2. If additional service treatment records are associated with the file, schedule a VA examination to be conducted by an appropriate clinician, to address the etiology of his claimed conditions. (i) The clinician should identify all current chronic disorders manifested by joint pain of the shoulders (to include tendonitis, impingement syndrome, subacromial bursitis, partial cuff tear), elbows, and hips. For each disorder identified, the clinician should address whether such disorder is at least as likely as not related to service. If a diagnosis cannot be provided but such condition manifests in symptoms that cause functional impairment, the examiner should consider the disorder a "disability" for the purpose of providing the above requested opinion. If a diagnosis cannot be provided and such condition DOES NOT manifest in symptoms that cause functional impairment, the examiner should address whether it least as likely as not that such symptomatology represents (a) an objective indication of chronic disability resulting from undiagnosed illness related to service in Persian Gulf, or (b) a medically unexplained chronic multi-symptom illness, defined by a cluster of signs or symptoms. The clinician is to provide a thorough rationale to support the opinion. (ii) The clinician should identify all current chronic disorders manifested by muscle pain and/or neurological symptoms of the neck, back, and legs. For each disorder identified, the clinician should address whether such disorder is at least as likely as not related to service. If a diagnosis cannot be provided but such condition manifests in symptoms that cause functional impairment, the examiner should consider the disorder a "disability" for the purpose of providing the above requested opinion. If a diagnosis cannot be provided and such condition DOES NOT manifest in symptoms that cause functional impairment, the examiner should address whether it least as likely as not that such symptomatology represents (a) an objective indication of chronic disability resulting from undiagnosed illness related to service in Persian Gulf, or (b) a medically unexplained chronic multi-symptom illness, defined by a cluster of signs or symptoms. The clinician is to provide a thorough rationale to support the opinion. (iii) The clinician should identify all current chronic disorders manifested by sleep disturbances (to include sleep apnea and insomnia). For each disorder identified, the clinician should address whether such disorder is at least as likely as not related to service. In addition, for a diagnosis of sleep apnea, the clinician should address whether it is at least as likely as not proximately due to or aggravated, i.e., worsened beyond its natural progression, by service-connected PTSD with major depressive disorder. If a diagnosis cannot be provided but such condition manifests in symptoms that cause functional impairment, the examiner should consider the disorder a "disability" for the purpose of providing the above requested opinion. If a diagnosis cannot be provided and such condition DOES NOT manifest in symptoms that cause functional impairment, the examiner should address whether it least as likely as not that such symptomatology represents (a) an objective indication of chronic disability resulting from undiagnosed illness related to service in Persian Gulf, or (b) a medically unexplained chronic multi-symptom illness, defined by a cluster of signs or symptoms. The clinician is to provide a thorough rationale to support the opinion. (iv) The clinician should identify any current chronic disorders manifested by fatigue. For each disorder identified, the clinician should address whether such disorder is at least as likely as not related to service. If a diagnosis cannot be provided but such condition manifests in symptoms that cause functional impairment, the examiner should consider the disorder a "disability" for the purpose of providing the above requested opinion. If a diagnosis cannot be provided and such condition DOES NOT manifest in symptoms that cause functional impairment, the examiner should address whether it least as likely as not that such symptomatology represents (a) an objective indication of chronic disability resulting from undiagnosed illness related to service in Persian Gulf, or (b) a medically unexplained chronic multi-symptom illness, defined by a cluster of signs or symptoms. The clinician is to provide a thorough rationale to support the opinion. (v) The clinician should identify all current chronic residuals of a head injury. For each disorder identified, the clinician should address whether such disorder is at least as likely as not related to service, to include to include the incident when the Veteran was hit on the top of his head with a crate holding rockets. If a diagnosis cannot be provided but such condition manifests in symptoms that cause functional impairment, the examiner should consider the disorder a "disability" for the purpose of providing the above requested opinion. (vi) The clinician should identify all current chronic cardiovascular disorders (to include hypertrophic cardiomyopathy, nonrheumatic mitral (valve) insufficiency, atrial fibrillation, essentially hypertension). For each disorder identified, the clinician should address whether such disorder is at least as likely as not related to service. In addition, for any diagnosis of hypertension, cardiovascular-renal disease, endocarditis, or myocarditis, the clinician should address whether such manifested within a year after discharge from service or was noted during service with continuity of the same symptomatology since service. The clinician is to provide a thorough rationale to support the opinion. (vii) The clinician should identify all current chronic lumbar spine disorders (to include degenerative disc disease and foraminal stenosis). For each disorder identified, the clinician should address whether such disorder is at least as likely as not related to service. In addition, for a diagnosis of lumbar spine arthritis, the clinician should address whether such manifested within a year after discharge from service or was noted during service with continuity of the same symptomatology since service. The clinician is to provide a thorough rationale to support the opinion. (viii) The clinician should identify all current chronic cervical spine disorders (to include cervicalgia, degenerative disc disease, spondylosis, radiculopathy, and spinal stenosis). For each disorder identified, the clinician should address whether such disorder is at least as likely as not related to service. In addition, for a diagnosis of cervical spine arthritis, the clinician should address whether such manifested within a year after discharge from service or was noted during service with continuity of the same symptomatology since service. The clinician is to provide a thorough rationale to support the opinion. In providing the requested opinions, 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 and symptoms 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? P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Olson, Patricia 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.