Citation Nr: 21074569 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 16-04 153 DATE: December 15, 2021 REMANDED The issue of service connection for a vestibular disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Air Force from May 1954 to July 1963. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2014 rating decision of the Fort Harrison, Montana Regional Office (RO). In October 2018, the Veteran was afforded a hearing before the undersigned Veterans Law Judge (VLJ) sitting at the Houston, Texas RO. During the hearing, the VLJ engaged in a colloquy with the Veteran toward substantiation of the claim. Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). In May 2021, the Board remanded the appeal to the RO for additional action. The RO did not substantially comply with the Board's remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Vestibular Disorder The matter is remanded for the following actions: 1. BACKGROUND FOR THE RO ADJUDICATOR In May 2021, the Board remanded the claim for a VA medical opinion as to whether the Veteran had a current diagnosis of a vestibular disorder, and if so, whether the vestibular disorder was caused by service. The September 2021 VA examiner provided the following opinions: (1) the Veteran did not have a diagnosis of a vestibular disorder, (2) there was no vestibular cause for the Veteran's dizziness and fainting, and (3) the Veteran's in-service dizziness was caused by dehydration and it was a self-limiting condition that resolved and that his current dizziness was not a manifestation of and/or caused by the in-service dizziness. In an October 2021 VA addendum, the examiner reviewed the Veteran's relevant post-service medical records and noted that the Veteran did not have a vestibular disorder diagnosis. However, remand is warranted to clarify (1) how the VA examiner determined that the Veteran's in-service dizziness was caused by dehydration and (2) how the in-service dizziness was a self-limiting condition that resolved because the Veteran's service treatment records do not show complaints or contemporaneous reports concerning dehydration. Stegall, 11 Vet. App. at 268. The Board has been unable to determine the source of the information as to the cause of the symptom in service was "dehydration." THE REMAND DIRECTIVES FOLLOW. 2. Return the file to the VA examiner who provided the September 2021 and October 2021 medical opinions for a file review and an addendum opinion. If the examiner is not available, have the file reviewed by a similarly qualified examiner. Another examination is not required; however, if the VA examiner indicates that he or she cannot respond to the Board's questions without examination of the Veteran, another examination should be afforded to the Veteran. All relevant medical and non-medical records must be available to the examiner for review of pertinent documents. The examination report should specifically state that such a review was conducted. The examiner must clarify the following: How was the Veteran's in-service dizziness caused by dehydration despite the lack of documented in-service reports of dehydration? Put simply, WHAT IS THE SOURCE OF THE EXAMINER'S INFORMATION THAT THE IN-SERVICE DIZZINESS WAS CAUSED BY THE VETERAN BEING DEHYDRATED? Why is the Veteran's in-service dizziness a self-limiting condition and how did it resolve? Although the examiner must review the VBMS file, his or her attention is drawn to the following: A September 1954 service treatment record reflects the Veteran's report of dizziness, temporary weakness, and instability. The authoring medical care provider indicated that no medications were prescribed and an examination was negative. In a May 1957 service department medical history questionnaire, the Veteran endorsed having had at some point "dizziness or fainting spells." However, the May 1957 service medical examiner noted "no reason given." The service medical examiner noted no neurological abnormalities. The examiner also noted the Veteran's previous report of dizziness and fainting spells but indicated that the Veteran did not then have complications or sequelae. In the Veteran's May 1963 pre-separation medical questionnaire, he denied then having or ever having had "dizziness or fainting spells." The service medical examiner noted no neurological abnormalities. A December 1998 VA treatment record reflects the Veteran's report of dizziness after being prescribed Maxzide. An October 1999 VA treatment record reflects the Veteran's report of dizziness once every two weeks. An April 2000 VA treatment record reflects the Veteran's report of dizziness after being prescribed Terazosin. A June 2000 VA treatment record reflects the Veteran's report of dizziness and he was diagnosed with orthostatic pulse change. An August 2000 VA treatment record reflects the Veteran's report of dizziness and relating his dizziness from wearing eyeglasses. A July 2002 VA treatment record reflects the Veteran's report of dizziness since 2000. A February 2003 VA treatment record reflects the Veteran's report of dizziness, giddiness, blurred vision, and trouble with balance since 2002. In a July 2013 statement, the Veteran alleged he had dizziness and fainting since June 1957. In the April 2014 VA central nervous examination, the Veteran reported dizziness. A July 2016 VA treatment record reflects the Veteran's report of dizziness lasting several seconds occurring every three months since 1954 and the VA treating physician noted that the Veteran's dizziness was consistent with a non-service-connected disorder. He has been denied service connection for a vascular disorder hypertension in three separate rating decisions under the Appeals Modernization Act (AMA). A February 2018 VA treatment record reflects the Veteran's report of lightheadedness. The Veteran was diagnosed with vertigo with post-tussive syncope. The VA treating physician indicated that the Veteran did not have benign paroxysmal positional vertigo (BPPV) and noted that the Veteran's dizziness was possibly related to high blood pressure, changes in medication, or high blood sugar. In his October 2018 Board hearing, the Veteran testified to having dizziness since September 1954. An April 2021 VA treatment record noted that the Veteran's dizziness "can be due to suboptimal titration of antihypertensive medication vs. syncope vs. posterior circulation dysfunction." In an April 2021 VA treatment record, a 20-year history of dizziness of noted. The Veteran reported dizziness, lightheadedness, but no "room-spinning" sensation. The Veteran also reported at least one syncopal episode, triggered with sudden changes in body position worsened upon standing and coughing. The VA staff neurologist noted that the Veteran's dizziness was "unclear etiology multifactorial" and that the "central cause unlikely given positional triggers." (CONTINUED ON THE NEXT PAGE) 3. Readjudicate the issue on appeal. If the benefit sought on appeal remains denied, the Veteran should be provided a supplemental statement of the case (SSOC). An appropriate period should be allowed for response before the case is returned to the Board. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Cohen, Counsel The Board's action is binding only in this case. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.