Citation Nr: 21073745 Decision Date: 12/10/21 Archive Date: 12/10/21 DOCKET NO. 16-39 902 DATE: December 10, 2021 REMANDED Entitlement to service connection for chronic fatigue syndrome (CFS) is remanded. Entitlement to service connection for a cerebral aneurysm is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1990 to April 2010, including overseas service in Southwest Asia. The Veteran appealed a March 2015 rating decision by the Agency of Original Jurisdiction (AOJ). The Board of Veterans' Appeals (Board) finds that further evidentiary development is necessary and remands the case to ensure compliance with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. CFS The December 2018 Board decision remanded the issue for a new examination with a qualified rheumatologist and/or immunologist to determine the nature and etiology of the Veteran's fatigue symptoms. However, it does not appear that the April 2019 examination report regarding CFS was conducted by a rheumatologist or immunologist. The April 2019 examiner did not find a diagnosis of CFS, but diagnosed the Veteran with anemias. Furthermore, a hematologic and lymphatic DBQ was completed in June 2020 regarding the Veteran's service-connected pancytopenia and noted fatigue and tiredness. This suggests that the Veteran's fatigue is a symptom of an already service-connected condition. Nevertheless, remand is required for a new examination with a qualified rheumatologist and/or immunologist in accordance with the December 2018 Board decision which covers all theories of entitlement. 2. Aneurysm The December 2018 Board decision remanded the issue for a new examination to determine the nature and etiology of the Veteran's aneurysm. The remand instructions called for opinions regarding whether the Veteran's condition pre-existed service, direct service connection, and secondary service connection to the Veteran's various service-connected disabilities. However, the April 2019 examination and various opinions do not provide adequate rationale. The opinions noted service treatment records (STRs) "do not show a history of headaches or a condition." However, the Board notes that the Veteran is competent to attest to the existence of headaches during and since service. Regarding secondary service connection, another clinician listed the Veteran's various service-connected conditions, found a negative nexus to them, and only stated that "there is no mention in the medical records of a SC condition that is associated with the development of a cerebral aneurysm." However, the opinion did not provide any rationale or any independent evaluation regarding secondary service connection. Finally, a third separate clinician in July 2020 was unable to state whether the Veteran's aneurysm clearly and unmistakably pre-existed service, but that it is likely a congenital condition and therefore pre-existed service since the Veteran's mother had an aneurysm and that most are congenital. It appears as if the opinion contradicts itself on whether the Veteran's condition pre-existed service. Furthermore, the opinion gives a generalization as to whether the Veteran's aneurysm is congenital. Nevertheless, the correct standards were not used and type of congenital condition was not identified. Overall, the Board finds the various opinions obtained on remand to be conclusory and without adequate rationale. As such, new opinions should be obtained on remand. The matters are REMANDED for the following action: 1. Obtain any outstanding VA and/or private treatment records relevant to treatment the Veteran received for his fatigue symptom and aneurysm that are not already of record. All obtained records should be associated with the evidentiary record. If any identified records are not obtainable (or none exist), the Veteran and his representative should be notified, and the record clearly documented. 2. Thereafter, schedule the Veteran for an examination by a qualified rheumatologist and/or immunologist to determine the nature and etiology of his fatigue symptoms. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. After the record review and examination of the Veteran, the examiner is asked to respond to the following inquiries: Has the Veteran had CFS at any point during the period on appeal? If no, is it at least as likely as not that any such fatigue symptoms had their clinical onset during active service or are related to any in-service disease, event, or injury, to include exposure to any environmental hazards while deployed to Southwest Asia? If a fatigue-related disability, other than chronic fatigue syndrome is diagnosed, is the etiology OR pathophysiology of the condition not conclusive as to this particular Veteran? Is it at least as likely as not that any fatigue-related disability, other than chronic fatigue syndrome, was caused or aggravated by the Veteran's service-connected pancytopenia? In rendering these opinions, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. A complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 3. After the development in #1 above is completed, obtain an opinion from a qualified clinician to determine the nature and etiology of the Veteran's aneurysm. The evidentiary record, including a copy of this remand, must be made available to and be reviewed by the reviewing clinician. It is up to the discretion of the reviewing clinician as to whether a new examination is necessary to provide an adequate opinion. After the record review and examination of the Veteran, if deemed necessary, the reviewing clinician is asked to respond to the following inquiries: Is the Veteran's aneurysm a (1) congenital "disease" or (2) a congenital or developmental "defect" or (3) an acquired disability? For VA purposes, "defects" are usually static in nature, whereas "diseases" are generally subject to episodic improvement or worsening." If the Veteran's aneurysm is a congenital or developmental defect, is it at least as likely as not that a superimposed disease or injury occurred during military service that resulted in an additional disability apart from the congenital or developmental defect? If the Veteran's aneurysm is a congenital disease, was it aggravated (worsened) by the Veteran's military service? If there was worsening, was this due to the natural progress of the disease? If the Veteran's aneurysm is an acquired disability, Did the Veteran's aneurysm clearly and unmistakably (undebatably) pre-exist his period of active duty? If yes, was the Veteran's aneurysm clearly and unmistakably (undebatably) NOT aggravated by service? If the reviewing clinician concludes the Veteran's aneurysm (1) did not clearly and unmistakably preexist service or (2) was not clearly and unmistakably not aggravated by service, the reviewing clinician should provide the following opinions: Is it at least as likely as not that the Veteran's aneurysm had its clinical onset during active service or is related to any in-service disease, event, or injury, to include exposure to any environmental hazards while deployed to Southwest Asia? Is the etiology OR pathophysiology of the Veteran's aneurysm not conclusive as to this particular Veteran? Is it at least as likely as not that the Veteran's aneurysm was CAUSED by a service-connected condition? Is it at least as likely as not that the Veteran's aneurysm was AGGRAVATED by a service-connected condition? In rendering these opinions, the reviewing clinician is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the reviewing clinician rejects the Veteran's reports, he or she must provide an explanation for such rejection. The reviewing clinician is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. A complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the reviewing clinician must provide a complete explanation for why an opinion cannot be rendered. In so doing, the reviewing clinician must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). (Continued on the next page) 4. After the above development has been completed to the extent possible, readjudicate the claims. If any benefit sought remains denied, provide the Veteran and his representative with a supplemental statement of the case (SSOC), and return the case to the Board, if otherwise in order. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Zheng, 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.