Citation Nr: 21074236 Decision Date: 12/14/21 Archive Date: 12/14/21 DOCKET NO. 09-30 031 DATE: December 14, 2021 REMANDED Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for a disability manifested by memory loss and fatigue is remanded. Entitlement to service connection for headaches with light sensitivity is remanded. Entitlement to service connection for alopecia is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from February 1987 to May 1991, with service in Southwest Asia from September 1990 to April 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). This matter was last before the Board in December 2017, at which time it was remanded for further evidentiary development. Unfortunately for the reasons discussed below another remand is again necessary. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. Following the Board's prior remand, an April 2021 rating decision granted service connection for eczema. As such, the previously remanded service connection claim for a skin rash has been resolved in full and is no longer before the Board. In August 2021, the Veteran was also awarded service connection for posttraumatic stress disorder. The Board notes that the Veteran previously perfected an appeal for sleep difficulties as due to undiagnosed illness, however chronic sleep impairment is a symptom of the Veteran's now service-connected PTSD, and is included in the disability rating for that condition. As such, service connection for sleep difficulties is currently in effect, and that claim of service connection is also resolved in full and no longer before the Board for adjudication. 1. Entitlement to service connection for a right shoulder disability is remanded. 2. Entitlement to service connection for a left shoulder disability is remanded. The Veteran asserts that he suffers from bilateral shoulder disabilities that had their onset during active military service. In August 2019, he underwent a VA examination where he was diagnosed with left shoulder arthritis, left shoulder bicipital tendon tear, left shoulder labral tear, and right shoulder tendonitis. However, the examiner's negative nexus opinion is conclusory and therefore inadequate to decide the respective claims. The examiner's opinion failed to address the Veteran's lay statements regarding the onset of his disabilities and also failed to discuss the relevance of a December 1987 service treatment record documenting an in-service right shoulder injury. Remand is needed to obtain more reasoned addendum opinions that address the Veteran's lay statements and the medical evidence of record. 3. Entitlement to a disability manifested by memory loss and fatigue is remanded. The Veteran contends that he suffers from a disability manifested by fatigue and memory loss that is related to his active service. The Board is unable to distinguish the extent to which these claimed symptoms are attributable to the disabilities of PTSD for which service connection is currently in effect, and obstructive sleep apnea for which a claim of service connection is pending. As the Veteran is considered a Persian Gulf veteran and reports multiple symptoms which can be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness, the Veteran should be scheduled for a specialized Gulf War examination to determine the nature and etiology of the claimed conditions, to include in light of the more recently diagnosed disabilities. 38 C.F.R. § 3.317. 4. Entitlement to service connection for headaches with light sensitivity is remanded. The Veteran contends that he suffers from headaches with light sensitivity related to active service. In August 2019, he underwent a VA examination where he was diagnosed with migraine headaches with migraine variants. However, the examiner's negative nexus opinion is inadequate to adjudicate the claim. The opinion fails to explain why the gap in time from the end of the Veteran's active service to the onset of his reported headache symptoms weighed against a finding that his headaches were unrelated to active service. Additionally, the opinion appears to take into consideration the Veteran's conceded exposure to environmental hazards while stationed in Southwest Asia. However, it is unclear what point the examiner was attempting to make regarding the Veteran's exposure to environmental hazards and its potential relationship to his diagnosed migraine headaches. Remand is needed to obtain a more reasoned addendum opinion. 5. Entitlement to service connection for alopecia is remanded. The Veteran contends that he suffers from hair loss due to environmental exposures during active service. In August 2019, he underwent a VA examination where he was diagnosed with alopecia. However, the examiner's negative nexus opinion is inadequate to adjudicate the claim. The examiner's rationale appears to be exclusively based on a lack of medical records documenting a chronicity of symptoms since service. No discussion was provided by the examiner on the possible relationship between the Veteran's hair loss and his conceded exposure to environmental hazards while stationed in Southwest Asia. Remand is therefore needed to obtain an addendum opinion. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records and associate them with the Veteran's claims folder. 2. Obtain an addendum medical opinion regarding the likely etiology of the Veteran's diagnosed bilateral shoulder disabilities. If the examiner determines that an opinion cannot be provided without an examination, then one should be scheduled (or telehealth interview, review of the record, etc., if an in-person examination is not feasible). Following review of the record, the clinician should answer the following questions: (a.) Please identify all diagnosed shoulder disabilities during the appeal period. (b.) Is it at least as likely as not (50 percent probability or greater) that any diagnosed shoulder disability identified above had its onset during service or is otherwise related to active service? 3. The examiner is asked to specifically address the Veteran's statements concerning the onset and progression of his shoulder disabilities, as well as the medical evidence of record, which includes a December 1987 service treatment record documenting an in-service shoulder injury. A complete rationale must be provided for all opinions. Schedule the Veteran for an appropriate examination to determine the nature and etiology of his reported symptoms including fatigue, memory loss, headache, and light sensitivities. The examiner should conduct all appropriate diagnostic testing. The examiner should then record all noted signs and reported symptoms, document all clinical findings, and provide a diagnosis if/where possible. The examiner is asked to provide responses to the following: (a.) Identify the Veteran's objective indications of a disability. "Objective indications" of a qualifying chronic disability include both objective evidence perceptible to an examining physician and other non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Non-medical indicators include evidence such as time lost form work, the veteran having sought treatment for his symptoms, and change in the veteran's appearance, physical abilities, and mental or emotional attitude. 60 Fed. Reg. 6661, 6663 (Feb. 3, 1995). (b.) By history, physical examination, or laboratory testing, can each of the Veteran's objective indications of a disability be attributed to a known clinical diagnosis? Please identify which objective indication can be attributed to which known clinical diagnosis (or multiple diagnoses) to the extent possible. If the signs and symptoms are not characteristic of a known clinical diagnosis, the examiner should so indicate. There is no requirement that the examiner provide a diagnosis of undiagnosed illness. (c.) If the Veteran's objective indications cannot be attributed to a known clinical diagnosis, is there affirmative evidence that the undiagnosed illness is not incurred during active service during the Persian Gulf War or that it was caused by a supervening condition or event that occurred since the Veteran's departure from service during the Persian Gulf War? The examiner should note that a positive response to this question requires affirmative evidence. The mere absence of evidence is not sufficient. (d.) If the Veteran's objective indications can be attributed to a known clinical diagnosis, is the etiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood? This determination as to each must be based on the Veteran's specific case and cannot be based on the etiology of the disease or disability population as a whole. (e.) If the Veteran's objective indications can be attributed to a known clinical diagnosis, is the pathophysiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood? This determination as to each must be based on the Veteran's specific case and cannot be based on the pathophysiology of the disease or disability population as a whole. (f.) If both the etiology and pathophysiology are partially understood or fully understood, then is it at least as likely as not (a 50 percent or greater probability) that the Veteran's diagnosed condition was incurred in, or is otherwise related to his active service, to include any environmental hazards experienced during that service? A complete rationale must be provided for all opinions expressed. 4. Obtain an addendum opinion regarding the likely etiology of the Veteran's diagnosed alopecia. If the examiner determines that an opinion cannot be provided without an examination, then one should be scheduled (or telehealth interview, review of the record, etc., if an in-person examination is not feasible). Following review of the record, the clinician should answer the following question: Is it at least as likely as not (50 percent probability or greater) that the Veteran's diagnosed alopecia had its onset during service or is otherwise related to active service, to include the Veteran's conceded exposure to environmental hazards while stationed in Southwest Asia? (Continued on the next page) The examiner is asked to specifically address the Veteran's statements concerning the onset and progression of his symptoms, as well as the medical evidence of record. A complete rationale must be provided for all opinions. K.B. McDonald Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Komperda, 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.