Citation Nr: 21075669 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 12-09 361 DATE: December 21, 2021 REMANDED Entitlement to service connection for a hair loss disability is remanded. Entitlement to service connection for a skin disability is remanded. Entitlement to service connection for a menstrual disorder, to include dysmenorrhea, is remanded. REASONS FOR REMAND The Veteran, who is the appellant in this case, had active United States Army service from May 1985 to September 1985 and from November 1990 to July 1991, and more than 20 years in the US Army Reserve Corps. In August 2016, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ); a transcript of the hearing is associated with the claims file. 1. Entitlement to service connection for a hair loss disability is remanded. 2. Entitlement to service connection for a skin disability is remanded. 3. Entitlement to service connection for a menstrual disorder, to include dysmenorrhea, is remanded. The Board last considered this appeal in June 2021 and remanded these issues for additional development. After the development was completed, the case returned to the Board for further appellate review. The Veteran's claim for a Gulf War undiagnosed illness or medically unexplained chronic multi symptom illness was previously recharacterized in the Board's January 2019 remand as six separate issues to more adequately address each individual symptom claimed. Clemons v. Shinseki, 23 Vet. App.1 (2009) (holding that when a claimant makes a claim, she is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled); see also Brokowski v. Shinseki, 23 Vet. App. 79 (2009). Subsequently, an April 2020 rating decision granted service connection for headaches and chronic fatigue syndrome. As this represents a full grant of these issues that were previously on appeal, they are no longer before the Board. The Board in a July 2020 decision denied separate service connection for muscle and joint pain and weakness because it found they are symptoms of the Veteran's service-connected back condition. Service connection for a low back strain was granted in a February 2012 rating decision. As part of the same Board decision, hair loss, skin disability, and menstrual disorder were remanded, because instead of opining whether the Veteran's hair loss, skin disability were at least as like as not related to service, the examiner only addressed whether the three disabilities were considered an undiagnosed illness or chronic multi symptom illness of unknown etiology. To remedy this the three issues were remanded in July 2020 with instructions to determine whether the Veteran has a disability that is separate and distinct from her service-connected disabilities rather than a symptom attributable to them. For each diagnosis identified, the examiner was asked to opine on the following: (a.) whether the Veteran's disability is at least as likely as not related to service, to include exposure to environmental hazards in Iraq. For hair loss, the examiner was also asked to assess whether it was proximately due to or aggravated beyond its natural progression by a service-connected disability to include medication to treat a service-connected disability. The examiner was specifically asked to address the Veteran's lay reports of onset for each disability and any relationship to service. The examiner was required to comment on the lay report of symptoms. After reviewing the 2020 opinions, the Board found further development was necessary. While the 2020 opinion diagnosed alopecia and provided an opinion and rationale as to direct service connection, the opinion concerning secondary service connection was conclusory and provided no rationale. While the 2020 examiner diagnosed dermatitis and menometrorrhagia, no opinion was provided. Most recently, the Board in a June 2021 decision remanded these issues to obtain addendum opinions to include secondary service connection and aggravation opinions for hair loss, and direct service connection opinions for any skin condition and a menstrual disorder as well as secondary and aggravation opinions. However, upon reviewing the August 2021 addendum opinions, the examiner copied and pasted the same opinion and rationale into the three possible ways to achieve service connection: Direct, secondary and aggravation for each issue. Because the opinions referenced medical treatises that proposed the most likely causes for each claimed issue and then pointed out that the Veteran's service-connected issues were not on the list, that approach may be adequate for direct service connection and secondary service connection opinions, but not aggravation. Aggravation is a different question, which is not answered by saying this "caused" it, and that did not. Therefore, the aggravation opinions and rationales are inadequate for the three issues remanded. Additionally, the examiner failed to address or discuss the Veteran's contentions that her claimed disabilities were caused by exposure to environmental hazards while serving in Iraq, namely exposure to factories, burning oil fields, burn pits, dust, and sandstorms. Also, in the November 2019 VA examination, the examiner who only opined as to whether the Veteran's claimed issues qualified as undiagnosed illnesses or chronic multi symptom illnesses of unknown etiology, suggested the possibility that the Veteran's anti-depressants taken for PTSD might have caused her alopecia, and the prednisone taken for her allergic issues may have caused her skin condition. The next examiner should discuss those possibilities and opine with rationales on these two service connection theories. Unfortunately, remand of the Veteran's claim for service connection for hair loss, skin disability, and menstrual disorder are warranted. Although the Board regrets the additional delay, further development of the record is required before the Board may render a decision in the instant case. When the Board's remand requests are not satisfied, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). The matters are REMANDED for the following action: 1. All relevant records, to include a copy of this Remand as well as the claims folder, must be made available to and reviewed by the reviewer/examiner in conjunction with the examination or review. The reviewer/examiner must confirm in the examination report that the claims folder was reviewed. Obtain addendum opinions from an appropriate clinician (and schedule any VA examinations if necessary) for hair loss. The examiner should determine: (a.) whether it is at least as likely as not (50 percent or greater) the hair loss was caused or aggravated by a service-connected disability to include the Veteran's anti-depressants taken for PTSD. A complete rationale for all opinions is required. 2. Obtain addendum opinions from an appropriate clinician (and schedule any VA examinations if necessary) for a skin rash, to include dermatitis. The examiner should determine: (a.) Whether it is at least as likely as not (50 percent or greater) any skin condition is related to service. In doing so, the examiner is specifically asked to address the Veteran's lay reports of onset for each disability, to include as due to exposure to environmental hazards in Iraq. (b.) whether it is at least as likely as not (50 percent or greater) any skin condition is caused or aggravated by a service-connected disability to include the prednisone taken for her allergic issues. A complete rationale for all opinions is required. 3. Obtain addendum opinions from an appropriate clinician (and schedule any VA examinations if necessary) for a menstrual disorder, to include dysmenorrhea and menometrorrhagia. The examiner should determine whether: (a.) it is at least as likely as not (50 percent or greater) the dysmenorrhea and menometrorrhagia are related to service? The examiner is specifically asked to address the Veteran's lay reports of onset, to include as due to exposure to environmental hazards in Iraq. (Continued on the next page) (b.) whether it is at least as likely as not (50 percent or greater) caused or aggravated by a service-connected disability. A complete rationale for all opinions is required. H. SEESEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Black, Jeffrey W. 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.