Citation Nr: 21075368 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 16-19 560A DATE: December 20, 2021 REMANDED Entitlement to service connection for anal fistula, to include status post fistulotomy, and as secondary to service connected hemorrhoids is remanded. REASONS FOR REMAND The Veteran served on active duty with the Navy from February 1983 to January 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In December 2019, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the evidentiary claims file. The Board remanded this appeal in October 2020 for additional development. The matter was last before the Board in August 2021. Service connection for hemorrhoids was granted, and entitlement to service connection for an anal fistula disability, to include as secondary to the newly service connected hemorrhoids, was remanded for a VA medical opinion. Although the Board regrets the additional delay, further development is needed prior to final adjudication. The Veteran contends he has an anal fistula disability from job duties in the service that led to hemorrhoids and preparation H use, or alternatively, is secondary to the now-service connected hemorrhoids. Specifically, he asserts that secondary service connection may be granted for worsening of a non-service connected condition by a service connected disability. See October 2021 IHP, at 2. Pursuant to the Board's August 2021 remand, the RO obtained a VA medical opinion on August 17, 2021. The examiner reviewed the evidentiary file, and provided a negative nexus opinion for direct service connection, opining that the anal fistula disability was less likely than not incurred in or caused by an in-service injury, event, or illness. See August 18, 2021 VA medical opinion. As no opinion was provided for secondary service connection, the RO requested a second opinion on the matter. On August 27, 2021, another VA examiner reviewed the Veteran's claims file and opined that it was less likely than not that the Veteran's service connected hemorrhoids caused the anal fistula disability. See August 27, 2021 VA medical opinion. However, the examiner did not provide an opinion on whether the anal fistula disability was aggravated by hemorrhoids or treatment for the condition. Aggravation must be discussed to resolve secondary service connection. See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (a medical opinion is inadequate when it fails to adequately address the question of aggravation). Thus, the Board finds the Veteran's service connection claim for anal fistula, to include status post fistulotomy, and as secondary to service connected hemorrhoids must be remanded for further development. The matters are REMANDED for the following action: 1. The RO should obtain a new VA medical opinion regarding entitlement to service connection for the Veteran's anal fistula disability, including as secondary to service connected hemorrhoids. The record and a copy of this remand must be made available to the examiner in conjunction with the request. The examiner must note that such review occurred. The Veteran should only be scheduled for examination if the examiner deems it is necessary to provide the requested opinion with rationale. First, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's anal fistula disability was caused by the service-connected hemorrhoid disability, to include manual reduction and/or the use of medications necessitated for treatment of hemorrhoids. Second, the examiner should also provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's anal fistula disability was aggravated (worsened beyond the normal progression of the disability) by the service-connected hemorrhoid disability, to include manual reduction and/or the use of medications necessitated for treatment of hemorrhoids. If aggravation is found, the examiner should also establish a baseline level of disability prior to aggravation. If unable to establish a baseline, the examiner should explain why. The examiner must provide a complete rationale for all opinions rendered. The examiner need only physically examine the Veteran if required to render an adequate opinion. 2. After completion of the above and any additional development deemed necessary, the issue on appeal should be reviewed with consideration of all applicable laws and regulations. If any benefit sought remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Gipson, 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.