Citation Nr: 21073971 Decision Date: 12/13/21 Archive Date: 12/13/21 DOCKET NO. 17-50 631 DATE: December 13, 2021 REMANDED Entitlement to service connection for fatigue, as secondary to medication for service-connected migraines and tremors, is remanded. Entitlement to service connection for gastroenteritis is remanded. Entitlement to service connection for upper and lower intestinal polyps is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from November 1982 to October 1991, and from December 2003 to July 2013. These claims come before the Board of Veterans' Appeals (Board) on appeal from October 2014 rating decisions by a Department of Veteran's Affairs (VA) Regional Office (RO). The Board previously remanded the Veteran's claims in January 2020. Although further delay is regrettable, the Board finds that a remand is necessary in this case to ensure that the Board's prior remand instructions are followed and that all records are reviewed by the RO and an appropriate clinician. 1. Entitlement to service connection for fatigue, as secondary to medication for service-connected migraines and tremors. The Veteran contends that he should be service connected for fatigue as secondary to medication he takes for his service-connected migraines and tremors. The Veteran was afforded a new VA examination in March 2020. The examiner conducted an in-person examination and reviewed the Veteran's e-folder. The examiner noted that the Veteran reported feeling tired all the time with generalized muscle weakness and insomnia. The examiner also stated that the Veteran is always tired, has poor concentration and if he does any physical activity, he is down for the next 24 hours. The examiner concluded that the Veteran's reported symptoms do not meet the VA diagnostic guidelines for a diagnosis of chronic fatigue syndrome. The examiner determined that the Veteran's claimed condition of chronic fatigue syndrome is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition as the Veteran does not have a diagnosis of chronic fatigue syndrome and therefore a nexus cannot be established. However, the examiner found that the Veteran does have mild to moderate fatigue. While the examiner determined that the Veteran's fatigue was not aggravated beyond its natural progression by a service-connected disability, the sole rationale provided was that the Veteran did not meet the criteria for chronic fatigue syndrome. In the present case, the record needs to identify any and all conditions manifested by fatigue and indicate whether it is at least as likely as not that the Veteran's fatigue symptoms are caused by or aggravated by medications taken to treat his service-connected disabilities. A clear rationale for this specific opinion must be provided. The Board provided very specific remand instructions in which the March 2020 examiner did not comply. These instructions were "provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran has a fatigue condition that is (1) proximately due to, or (2) aggravated beyond its natural progression by side effects of taking Propranolol for his migraines and tremors." Merely noting that the Veteran does not have the specific diagnosis of chronic fatigue syndrome does not answer the aforementioned questions. Compliance with remand directives is not optional or discretionary, and the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). Therefore, remand is necessary to consider whether the Veteran's symptoms of fatigue are proximately due to or aggravated by the medications that the Veteran takes for his service-connected condition. 2. Entitlement to service connection for gastroenteritis. See paragraph 3. 3. Entitlement to service connection for upper and lower intestinal polyps. The Board acknowledges that the Veteran's private treatment records were obtained from MedStar Shah Medical Group in 2020. However, the last VA examination that the Veteran had to assess the nature and etiology of the Veteran's gastroenteritis and upper and lower intestinal polyps was in 2014. A new medical opinion is necessary to interpret the Veteran's medical records most recently obtained and associated with the claims file. The matters are REMANDED for the following action: 1. Obtain any outstanding medical records and associate them with the Veteran's claims file. Any efforts to obtain outstanding records should be documented in the claims file. 2. Schedule the Veteran for a new VA examination as it relates to the Veteran's claimed chronic fatigue syndrome. The clinician is asked to provide an opinion as to the relationship between the Veteran's symptoms of fatigue and difficulty functioning and the medication the Veteran takes for his service-connected migraines and tremors. Specifically, after examination and review of the medical history, the examiner is asked to provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran has a fatigue condition that is (1) proximately due to, or (2) aggravated beyond its natural progression by side effects of taking Propranolol for his migraines and tremors. The VA examiner must provide separate findings and rationales relating to causation and aggravation. The examiner is instructed that if it is again determined that the criteria for establishing a diagnosis of chronic fatigue syndrome are not met, this in and of itself does not answer the above questions, as symptomatology alone resulting in functional impairment can in certain circumstances be viewed as a disability without a formal diagnosis. A complete rationale must be provided for any opinion expressed. A complete rationale must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. 3. Obtain an updated medical opinion for the Veteran's gastroenteritis and upper and lower intestinal polyps. A physical examination is not required unless deemed necessary by the examining clinician. The Board asks that the clinician take all of the Veteran's medical records into consideration, particularly the records from MedStar Shah Medical Group associated with the record since the Board's January 2020 remand. The clinician is asked to provide an opinion as to the nature and etiology of the Veteran's gastroenteritis and upper and lower intestinal polyps, addressing the following: a) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran's gastroenteritis manifested during, or as a result of, the Veteran's active military service? Additionally, is it at least as likely as not (a 50 percent probability or greater) that any such disorder is either caused by or aggravated by, the Veteran's service-connected conditions (to include any associated medications)? b) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran's upper and lower intestinal polyps manifested during, or as a result of, the Veteran's active military service? Additionally, is it at least as likely as not (a 50 percent probability or greater) that any such disorder is either caused by or aggravated by, the Veteran's service-connected conditions (to include any associated medications)? A complete rationale must be provided for any opinion expressed. A complete rationale must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before a more conclusive opinion could be rendered. 4. Then, readjudicate the claims on appeal. If any benefits sought on appeal remain denied, provide a supplemental statement of the case to the Veteran and return the appeal to the Board for appellate review, after the Veteran and his representative have had an adequate opportunity to respond. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Hailu, 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.