Citation Nr: 21074548 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 16-36 927 DATE: December 15, 2021 REMANDED Entitlement to service connection for an autoimmune disorder, to include systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), is remanded. Entitlement to service connection for myasthenia gravis is remanded. Entitlement to service connection for peripheral neuropathy is remanded. Entitlement to service connection for the Veteran's cause of death is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1967 to November 1969. The Veteran died in May 2017 and his spouse has been substituted as the appellant. This matter comes before the Board of Veterans' Appeals (Board) on appeal from February 2011 and August 2017 rating decisions issued by a Department of Veterans Affairs (VA) agency of original jurisdiction (AOJ). The Board recognizes that the February 2011 rating decision denied entitlement to SLE and RA as two separate disabilities, and the notice of disagreement only listed SLE as appealed. However, the Veteran's original claim was for "lupus/RA" and a note from Dr. R.P. states that "I have been treating [the Veteran] for an autoimmune disease characterized by features of both systemic lupus erythematosus and rheumatoid arthritis." As such, the Board finds that the Veteran's claim for SLE also encompasses RA, and the claim has been recharacterized as such. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). 1. Entitlement to service connection for an autoimmune disorder, to include SLE and RA. 2. Entitlement to service connection for myasthenia gravis. The Appellant contends that the Veteran's SLE, RA, and myasthenia gravis are related to his herbicide agent exposure during service. The record contains a November 2009 private provider opinion from Dr. R.P. that stated that exposure to toxic chemical/agents during service certainly could have played a role in precipitating some of the Veteran's problems for which he is under the doctor's care. The May 2020 remand order asked the VA examiner to specifically comment on the positive opinion from Dr. R.P. VA obtained a June 2020 VA examiner opinion. The examiner did not comment on the positive opinion from Dr. R.P., and as such the appeals were remanded again. June 2021 and September 2021 VA examiner opinions were obtained where the examiner stated that it was at least as likely as not that the Veteran's SLE and myasthenia gravis were less likely than not incurred in or caused by the claimed in service injury, event, or illness. The examiner's rationale appears to be language copied from the National Academy of Sciences (NAS) 2018 report stating that "the committee concludes that there is inadequate or insufficient evidence to determine whether there is an association between exposure to COIs and any specific disease involving immune suppression, allergy, autoimmunity, or inflammation." This rationale is generic, not specific to the Veteran and his impairments, and the doctor did not appear to provide any rationale aside from language copied from the report. As such, a new examination with adequate rationale is required. Barr v. Nicholson, 21 Vet. App. 303 (2007). 3. Entitlement to service connection for peripheral neuropathy. The claim of service connection for peripheral neuropathy is inextricably intertwined with the claim of entitlement to an autoimmune disorder to include SLE and RA. August 2011 VA Medical Center treatment records indicate that the most recent note from neurology states that they believe his polyneuropathy was from his rheumatoid arthritis. Therefore, the issue of secondary service connection for peripheral neuropathy has been raised by the record. Development undertaken for the Veteran's autoimmune disorders, to include SLE and RA, will bear directly on the question of whether the Veteran is entitled to service connection for peripheral neuropathy. Therefore, a decision on this matter is deferred pending development on the claim of entitlement to service connection for SLE and RA. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). 4. Entitlement to service connection for the Veteran's cause of death. The appellant's claim for service connection for cause of death is inextricably intertwined with the claims of entitlement to service connection for SLE and myasthenia gravis. See Harris, 1 Vet. App. at 183 (1991). Development undertaken for the Veteran's service connection claims will bear directly on the question of whether the Veteran is entitled to service connection for cause of death. Therefore, a decision on this matter is deferred pending development on the service connection claims. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from a VA examiner regarding the nature and etiology of the Veteran's SLE, RA, and myasthenia gravis. If possible, the VA examiner should be a specialist in autoimmune disorders, such as a rheumatologist. The claims file, including a copy of this Remand, must be made available to the examiner for review. Following a review of the record, the examiner is asked to provide a response to the following (each opinion must be supported by rationale): (a.) Was the Veteran's systemic lupus erythematosus or rheumatoid arthritis at least as likely as not (a 50 percent or greater probability) related to service, to include the Veteran's conceded exposure to herbicide agents during service? (b.) Was the Veteran's myasthenia gravis at least as likely as not (a 50 percent or greater probability) related to service, to include the Veteran's conceded exposure to herbicide agents during service? The examiner must explicitly address the November 2009 private opinion from Dr. R.P., and reconcile any opinion with the opinions already of record. A detailed explanation is required to support the opinion. A complete and thorough rationale must be provided for any opinions expressed with consideration given to all evidence of record. If the examiner is unable to offer the opinion requested, he or she must explain in detail why that is the case. If the inability to opine is due to the fact that the examiner lacks the expertise to render such an opinion, or due to the fact that some additional testing or information is needed, and possibly available, that would permit such an opinion, the examiner should clearly and specifically state so, and, if applicable, the examiner should also state precisely what additional testing or information is needed in order to render the requested opinion. 2. If the VA examiner offers an opinion that the Veteran's SLE or RA are related to service, the AOJ should obtain an opinion on the following: (a.) Was the Veteran's peripheral neuropathy at least as likely as not (a 50 percent or greater probability) caused by the Veteran's SLE or RA? (b.) Was the Veteran's peripheral neuropathy at least as likely as not aggravated (worsened) by the Veteran's SLE or RA? 3. Following obtaining these opinions, the AOJ should undertake any development necessary with respect to the cause of death claim. Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Patrick, 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.