Citation Nr: 21074026 Decision Date: 12/14/21 Archive Date: 12/14/21 DOCKET NO. 17-05 987 DATE: December 14, 2021 REMANDED Entitlement to service connection for chronic headaches and migraines, to include as secondary to Gulf War Illness is remanded. Entitlement to service connection for a back disorder, to include as secondary to Gulf War Illness is remanded. Entitlement to service connection for chronic nerve pain, to include as secondary to Gulf War Illness is remanded. Entitlement to service connection for a right knee disorder, to include as secondary to Gulf War Illness is remanded. Entitlement to service connection for appendix cancer and residuals, to include as secondary to Gulf War Illness is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1984 to October 1984 and from September 1990 to June 1991, with service in the Southwest Asia theater of operations in the Persian Gulf. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In August 2019, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that proceeding has been associated with the record. The Board previously remanded the case in December 2019 for further development. While on remand, the RO granted service connection for fibromyalgia, irritable bowel syndrome (IBS), chronic fatigue syndrome (CFS), and hypertension. These grants of service connection represent the full benefits sought on appeal and the matters are no longer for appellate consideration. 1. Entitlement to service connection for chronic headaches and migraines, to include as secondary to Gulf War Illness is remanded. The Veteran is seeking to establish service connection for chronic headaches and migraines which she contends are associated with her service in the Southwest Asia theater. In a March 2020 VA examination for headaches, including migraine headaches, the VA examiner noted a diagnosis of migraine including migraine variants. Symptoms included pulsating or throbbing head pain, pain localized to one side of the head, worsening pain with activity, nausea, and sensitivity to light. In a November 2020 addendum opinion, the examiner found that the Veteran's chronic headaches and migraines were as least as likely as not related to service, noting that the condition was part of a multi-system illness associated with the environmental hazards in Southwest Asia along with CFS and fibromyalgia. The Board notes that the Veteran has been granted service-connection for CFS and fibromyalgia and March 2020 VA examination reports indicate that headaches are a symptom of each condition. However, the Veteran contends she experienced headaches as a teenager and began experiencing them again after she returned from overseas. The Board finds that it is unclear whether the Veteran's chronic headaches and migraines are only symptoms of her service-connected CFS and fibromyalgia or if her headaches and migraines are their own separate diagnosis, potentially aggravated by her CFS and fibromyalgia. As such, remand for an addendum opinion to provide clarification is warranted. 2. Entitlement to service connection for a back condition, to include as secondary to Gulf War Illness is remanded. 3. Entitlement to service connection for chronic nerve pain, to include as secondary to Gulf War Illness is remanded. The Veteran is seeking to establish service connection for a back condition and chronic nerve pain, which has been diagnosed as bilateral sciatica secondary to her back condition. In a December 2020 addendum opinion, a VA examiner noted that the Veteran reported she fell while working in May 2015 and landed on her back when she was transferring a patient from sitting to standing. The examiner noted that in conclusion, there was medical evidence to show cause for back pain. As this incident was during a period following service, the RO continued the denial of the Veteran's claims. Unfortunately, the Board finds that a remand is again warranted, as the December 2020 addendum is inadequate for adjudication purposes. Treatment records reflect that mild arthritis was seen by imaging studies as early as 2012. Further, in a March 2020 VA examination, the Veteran reported back pain that began in 1991 after filling and moving sandbags. A service treatment record from September 1990 reflects that the Veteran visited sick call due to complaints that her whole body was sore and was diagnosed with musculoskeletal pain. The examiner's December 2020 addendum opinion fails to reflect review of pertinent records prior to 2015 or consideration of the Veteran's statements. As such, remand for a new addendum opinion is warranted. 4. Entitlement to service connection for a right knee condition, to include as secondary to Gulf War Illness is remanded. The Veteran is seeking to establish service connection for a right knee condition. She contends her right knee condition is etiologically linked to service. The Veteran was afforded a VA examination for the knees in March 2020. The VA examiner diagnosed right side MCL sprain and opined that the condition was as least as likely as not related to service. However, the examiner simply listed information from treatment records and regulations pertaining to Gulf War Illness and failed to provide a supporting rationale. In a November 2020 addendum opinion, the examiner revised his opinion, noting that "based on no evidence of record [...] this right knee disorder, MCL sprain, is less likely than not incurred in or caused by any claimed in service injury, event, or illness." Unfortunately, the Board finds that a remand is again warranted, as the November 2020 addendum is inadequate for adjudication. The examiner failed to address a September 1990 service treatment record that showed the Veteran visited sick call complaining that her whole body was sore and was diagnosed with musculoskeletal pain. Further, the examiner's opinion does not reflect any consideration of the Veteran's statements that her knee pain began in service. As such, remand for a new addendum opinion is warranted. 5. Entitlement to service connection for appendix cancer and residuals, to include as secondary to Gulf War Illness is remanded. The Veteran is seeking to establish service connection for appendix cancer and residuals associated with her appendix cancer. Treatment records reflect that the Veteran underwent an appendectomy in 2011. The pathology report was positive for a 1.2 cm well-differentiated neuroendocrine tumor. Recommended treatment with simple appendectomy was conducted. The Veteran was afforded a VA examination for intestinal conditions in March 2020. Diagnoses of IBS, chronic diarrhea, and diverticulitis were noted. The Veteran's intestinal conditions were noted to cause alternating diarrhea and constipation, nausea, and occasional episodes of bowel disturbance with abdominal distress. The VA examiner indicated that the Veteran had a history of appendectomy with carcinoid tumors but did not currently have any residual conditions or complications due to the neoplasm or its treatment other than what was documented in the examination report. The Veteran was also afforded a VA examination for stomach and duodenal conditions in March 2020. A diagnosis of gastritis was noted, with symptoms that included abdominal pain and nausea. The VA examiner indicated that the Veteran had hypertrophic gastritis with no symptoms or findings. The examiner noted that the Veteran's GERD and diverticulitis were related to her gastritis. Finally, the examiner remarked that there was no diagnosis for the Veteran's claimed abdominal condition with chronic pain because there were no findings, signs or symptoms to support a diagnosis. In December 2020, the examiner rendered an addendum opinion noting that there was a relationship between gastritis and appendix cancer. The examiner also indicated that the Veteran was exposed to burn pits during her active duty and their relationship to various cancers was noted. Further, the examiner added that the Veteran was in remission for alcohol and cannibis use and alcohol was a contributing factor to various cancers of the body. Unfortunately, the Board finds that a remand is again warranted, as the March 2020 VA examinations and December 2020 addendum are inadequate for adjudication. It is unclear whether the Veteran suffers from a current disability related to her appendix cancer or residuals of her appendix cancer and if so, whether associated symptoms are separate from her service-connected IBS. As such, remand for a new VA examination is warranted. The matters are REMANDED for the following action: 1. The Veteran should be afforded an additional opportunity to provide information necessary to obtain outstanding private treatment records related to her claimed disabilities. All records and/or responses should be associated with the claims file. 2. After any records obtained have been associated with the evidentiary record, schedule the Veteran for a VA examination for her appendix cancer and residuals. The examiner must review the claims file. Importantly, the VA examiner should allow the Veteran's sister, Ms. [REDACTED], to be present during the Veteran's examination. The examiner is asked to provide a response to the following: a) Does the Veteran currently (during the appeal period beginning in November 2015) have a diagnosis of appendix cancer or residuals of appendix cancer? Please list all residuals, if any. b) If the Veteran has a current diagnosis of appendix cancer or residuals related to appendix cancer, determine whether it is as least as likely as not (i.e., a 50 percent or greater probability) that the condition onset during service or is otherwise casually related to any event or circumstance of service, to include as part of a Gulf War illness. The examiner's opinion should reflect consideration of the Veteran's statements regarding onset, symptoms, and continuity of her claimed disability. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 3. After any records obtained have been associated with the evidentiary record, obtain an addendum opinion from an appropriate clinician, regarding the Veteran's chronic headaches and migraines. The claims file and a copy of this remand must be made available to the examiner. The need for an examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinions. The examiner should respond to the following: a) Are the Veteran's chronic headaches and migraines a symptom or manifestation of her service-connected fibromyalgia and/or CFS or a separate and distinct disability? b) If the Veteran's chronic headaches and migraines are a separate and distinct disability, determine whether it is as least as likely as not (i.e., a 50 percent or greater probability) that the condition had its onset during service or is otherwise causally related to any event or circumstance of the Veteran's service, to include as part of a Gulf War illness. The examiner's opinion should reflect consideration of the Veteran's statements regarding onset, symptoms, and continuity of her claimed disability. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 4. After any records obtained have been associated with the evidentiary record, obtain an addendum opinion from an appropriate clinician, regarding the Veteran's back condition and associated chronic nerve pain. The claims file and a copy of this remand must be made available to the examiner. The need for an examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinions. The examiner should respond to the following: Determine whether it is as least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's back condition and associated chronic nerve pain had its onset during service or is otherwise causally related to any event or circumstance of the Veteran's service, to include as part of a Gulf War illness. The examiner's opinion should reflect consideration of the Veteran's statements regarding onset, symptoms, and continuity of her claimed disability, as well as treatment records showing lumbar degenerative arthritis as early as 2012. A September 1990 service treatment record noting a diagnosis of musculoskeletal pain should be addressed. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 5. After any records obtained have been associated with the evidentiary record, obtain an addendum opinion from an appropriate clinician, regarding the Veteran's right knee condition. The claims file and a copy of this remand must be made available to the examiner. The need for an examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinions. The examiner should respond to the following: Determine whether it is as least as likely as not (i.e., a 50 percent or greater probability) that the right knee condition had its onset during service or is otherwise causally related to any event or circumstance of the Veteran's service, to include as part of a Gulf War illness. The examiner's opinion should reflect consideration of the Veteran's statements regarding onset, symptoms, and continuity of her claimed disability. A September 1990 service treatment record noting a diagnosis of musculoskeletal pain should be addressed. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 6. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, furnish the Veteran and her representative a supplemental statement of the case (SSOC) and return the case to the Board. KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Silverblatt, 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.