Citation Nr: 21076898 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 19-30 309 DATE: December 28, 2021 REMANDED The issue of entitlement to service connection for an autoimmune disorder manifested by hair loss is remanded. The issue of entitlement to service connection for a skin condition claimed as photosensitivity with melasma is remanded. The issue of entitlement to service connection for an irregular menstrual cycle is remanded. The issue of entitlement to service connection for loss of an ovary secondary to an irregular menstrual cycle is remanded. The issue of entitlement to service connection for a right kidney condition is remanded. The issue of entitlement to service connection for a left hip disability is remanded. The issue of entitlement to service connection for a right hip disability is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1978 to July 1982 with additional service in the Army National Guard. These matters come before the Board of Veterans' Appeals (Board) on appeal from June 2017 and November 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). Jurisdiction is currently with the RO in Cleveland, Ohio. The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) via videoconference in May 2021 and a transcript of the hearing has been associated with the claims file. Service connection for a low back disability was granted in an August 2019 rating decision. The Board finds that this grant represents a complete grant of the benefits sought on appeal; thus, the aforementioned issue is no longer before the Board. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997) (holding that where an appealed claim for service connection is granted during the pendency of the appeal, a second notice of disagreement must thereafter be timely filed to initiate appellate review of the claim concerning "downstream" issues, such as the compensation level assigned for the disability and the effective date); see also 38 C.F.R. § 20.200. The Board has expanded the claim of service connection for photosensitivity with melasma to one for service connection for a skin condition. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled). 1. Entitlement to service connection for an autoimmune disorder manifested by hair loss is remanded. The Veteran has not yet been afforded a VA examination in connection with her claim. VA must provide an examination when there is competent evidence of a disability (or persistent or recurrent symptoms of a disability) that may be associated with an in-service event, injury, or disease, but there is insufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Lay testimony as to continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service, and the threshold for finding that the disability (or symptoms of a disability) may be associated with service is low. Id. at 83. Furthermore, the Veteran is competent to testify to in-service injuries, symptoms, and events. Jandreau v. Nicholson, 492 F.3d 1372, 1372 (Fed. Cir. 2007). The Veteran contends that she has an autoimmune disorder manifested by hair loss as a result of in-service toxic exposures. The Veteran testified during the May 2021 Board hearing that she first experienced hair loss in service. The Veteran is competent to provide testimony concerning factual matters of which she has firsthand knowledge, such as experiencing a physical symptom such as hair loss. Barr v. Nicholson, 21 Vet. App. 303 (2007). Post-service medical treatment records document alopecia and abnormal rheumatology testing that raised questions about lupus. See August 2016 Cleveland VAMC Records. The Board therefore finds that the threshold of the McLendon standard has been met, and that the Veteran should be afforded an initial VA examination addressing whether an autoimmune disorder manifested by hair loss was incurred in or aggravated by military service. McLendon, 20 Vet. App. at 81. 2. Entitlement to service connection for a skin condition is remanded. The Veteran contends that she has a skin condition as a result of in-service exposures. The Veteran testified during the May 2021 Board hearing that she first experienced symptoms of itchiness and photosensitivity during service. Barr, 21 Vet. App. at 303. Post-service medical treatment records document diagnoses of chronic pruritis and melasma and complaints of photosensitivity. See July 2016 and August 2016 Cleveland VAMC Records. The Board therefore finds that the threshold of the McLendon standard has been met, and that the Veteran should be afforded an initial VA examination addressing whether a skin condition was incurred in or aggravated by military service. McLendon, 20 Vet. App. at 81. 3. Entitlement to service connection for an irregular menstrual cycle is remanded. The Veteran contends that she has an irregular menstrual cycle as a result of in-service toxic exposures. The Veteran testified during the May 2021 Board hearing that she first experienced an irregular menstrual cycle (prolonged cycle, heavy bleeding, pain, etc.) during service which continued thereafter. Barr, 21 Vet. App. at 303. The Veteran further testified that a clinician put her on birth control to regulate her menstrual cycle during service. The Veteran's service treatment records (STRs) document that the Veteran consented to ICUD insertion. The Board therefore finds that the threshold of the McLendon standard has been met, and that the Veteran should be afforded an initial VA examination addressing whether an irregular menstrual cycle was incurred in or aggravated by military service. McLendon, 20 Vet. App. at 81. 4. Entitlement to service connection for loss of an ovary secondary to an irregular menstrual cycle is remanded. As the issue of entitlement to service connection for an irregular menstrual cycle is being remanded for further development, decision by the Board on the issue of entitlement to service connection for loss of an ovary secondary to an irregular menstrual cycle would, at this point, be premature. Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc). Therefore, the appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to remand the claim on appeal pending the adjudication of the inextricably intertwined claim. Harris v. Derwinski, 1 Vet. App. 180 (1991). 5. Entitlement to service connection for a right kidney condition is remanded. The Veteran contends that she has a right kidney condition as a result of in-service toxic exposures. Alternately, the Veteran contends that she has a right kidney condition as a result of an in-service fall. STRs document an in-service fall. Post-service medical treatment records document a diagnosis of renal cyst/7mm non-enhancing. See September 2015 Sandusky CBOC Records. The Board therefore finds that the threshold of the McLendon standard has been met, and that the Veteran should be afforded an initial VA examination addressing whether a right kidney condition was incurred in or aggravated by military service. McLendon, 20 Vet. App. at 81. 6. Entitlement to service connection for a left hip disability is remanded. 7. Entitlement to service connection for a right hip disability is remanded. The Veteran contends that she has a left hip disability and a right hip disability secondary to her service-connected low back disability. Specifically, the Veteran contends that her service-connected low back disability altered her gait. In this regard, the evidence of record includes June 2019 VA Hip and Thigh Conditions examination report in which the examiner opined that the condition claimed was less likely than not proximately due to or the result of the Veteran's service-connected condition. The examiner reasoned that the lower back arthritis condition cannot biomechanically result in a bilateral hip condition as per the review of the medical literature. The Board finds the June 2019 VA examiner opinion inadequate to decide the Veteran's claim for service connection for a left hip disability and service connection for a right hip disability. First, the examiner's rationale falls short of an analysis or rationale that the Board can consider and weigh against contrary opinions. Second, the June 2019 examiner opinion did not address aggravation. A medical opinion regarding secondary service connection must address both causation and aggravation. See El Amin v. Shinseki, 26 Vet. App. 140 (2013). Third, the Board notes that the evidence of record contains additional contentions which have not yet been addressed. Specifically, the Veteran contends that she has a left hip disability and right hip disability as a result of an in-service fall(s): (1) fell off a 12 ton truck (2) fell when the ground gave way while marching in basic training. The Veteran's STRs document an in-service fall. Therefore, an addendum opinion should be obtained on remand. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (stating that, when VA undertakes to provide a veteran with an examination, that examination must be adequate for VA purposes). The matters are REMANDED for the following action: 1. Request that the Veteran provide or authorize VA to obtain records of her relevant treatment that have not yet been associated with the claims file, and associate with the claims file any outstanding VA treatment records. 2. Ensure that the Veteran's complete military personnel records are associated with the claims file. The Board Is particularly interested in any hospital records from Heidelberg, Germany; Fort McClellan; or West Fort Hood. 3. Conduct appropriate development to verify any potential exposures to nuclear toxic waste, herbicide agents, or gases during the Veteran's service at West Fort Hood and Fort McClellan. The Veteran reports that she guarded the woods where environmental/nuclear hazards were stored. The Veteran reports that there was also wide contamination of toxic waste. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of her autoimmune disorder manifested by hair loss. The claims file (including any additional medical evidence obtained as a result of this Remand) should be made available to the examiner and review of the file should be noted in the requested report. The examiner should record the full history of the identified disability, including the Veteran's competent account of his symptoms. Following review of the claims file and examination of the Veteran the examiner should respond to the following: (a.) Is it at least as likely as not (50 percent probability or greater) that the Veteran has an autoimmune disorder manifested by hair loss that had its onset during active service or within one year of the Veteran's separation from active service, or is otherwise related to service? The examiner is asked to discuss the Veteran's contention that she has an autoimmune disorder manifested by hair loss as a result of in-service toxic exposures and her contention that she first experienced hair loss in service. The examiner is also asked to discuss the buddy statements of record and post-service medical treatment records which document alopecia and abnormal rheumatology testing that raised questions about lupus. (b.) All findings and conclusions should be supported with a complete rationale and set forth in a legible report, which should reflect the examiner's consideration and analysis of both the medical and lay evidence of record. If it is not possible to provide an opinion without resort to speculation, the reason that is so should be explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge. 5. Schedule the Veteran for a VA examination to determine the nature and etiology of her skin condition. The claims file (including any additional medical evidence obtained as a result of this Remand) should be made available to the examiner and review of the file should be noted in the requested report. The examiner should record the full history of the identified disability, including the Veteran's competent account of his symptoms. Following review of the claims file and examination of the Veteran the examiner should respond to the following: (a.) Is it at least as likely as not (50 percent probability or greater) that the Veteran has a skin condition that had its onset during active service or within one year of the Veteran's separation from active service, or is otherwise related to service? The examiner is asked to discuss the Veteran's contention that she first experienced symptoms of itchiness and photosensitivity during service and her contention that she was burned in a gas chamber during basic training. The examiner is also asked to discuss the buddy statements of record and post-service diagnoses of chronic pruritis and melasma. Finally, the examiner is asked to address the relationship, if any, between the Veteran's in-service prescription of birth control and any current melasma. (b.) All findings and conclusions should be supported with a complete rationale and set forth in a legible report, which should reflect the examiner's consideration and analysis of both the medical and lay evidence of record. If it is not possible to provide an opinion without resort to speculation, the reason that is so should be explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge. 6. Schedule the Veteran for a VA examination to determine the nature and etiology of her irregular menstrual cycle/loss of an ovary. The claims file (including any additional medical evidence obtained as a result of this Remand) should be made available to the examiner and review of the file should be noted in the requested report. The examiner should record the full history of the identified disability, including the Veteran's competent account of his symptoms. Following review of the claims file and examination of the Veteran the examiner should respond to the following: (a.) Is it at least as likely as not (50 percent probability or greater) that the Veteran has an irregular menstrual cycle that had its onset during active service or within one year of the Veteran's separation from active service, or is otherwise related to service? The examiner is asked to discuss the Veteran's contention that she first experienced an irregular menstrual cycle (prolonged cycle, heavy bleeding, pain, etc.) during service which continued thereafter. The examiner is also asked to discuss the Veteran's contention that a clinician put her on birth control to regulate her menstrual cycle during service and consent to ICUD insertion documented in the Veteran's STRs. (b.) Is it at least as likely as not (50 percent probability or greater) that the Veteran's loss of an ovary that had its onset during active service or within one year of the Veteran's separation from active service, or is otherwise related to service? The examiner is asked to discuss the Veteran's in-service falls: (1) fell off a 12 ton truck (2) fell when the ground gave way while marching in basic training. (c.) If the Veteran has an irregular menstrual cycle related to her active service, is it at least as likely as not that the Veteran's loss of an ovary was caused or aggravated by her irregular menstrual cycle? Please address both causation and aggravation separately and explain why or why not. (d.) If the examiner finds the Veteran's loss of an ovary was aggravated by her irregular menstrual cycle, he/she should attempt to quantify the degree of aggravation beyond the baseline level. (e.) All findings and conclusions should be supported with a complete rationale and set forth in a legible report, which should reflect the examiner's consideration and analysis of both the medical and lay evidence of record. If it is not possible to provide an opinion without resort to speculation, the reason that is so should be explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge. 7. Schedule the Veteran for a VA examination to determine the nature and etiology of her right kidney condition. The claims file (including any additional medical evidence obtained as a result of this Remand) should be made available to the examiner and review of the file should be noted in the requested report. The examiner should record the full history of the identified disability, including the Veteran's competent account of his symptoms. Following review of the claims file and examination of the Veteran the examiner should respond to the following: (a.) Is it at least as likely as not (50 percent probability or greater) that the Veteran has a right kidney condition that had its onset during active service or within one year of the Veteran's separation from active service, or is otherwise related to service? The examiner is asked to discuss the Veteran's contention that she has a right kidney condition as a result of in-service toxic exposures and her contention that she has a right kidney condition as a result of an in-service fall: (1) fell off a 12 ton truck (2) fell when the ground gave way while marching in basic training. The examiner is also asked to discuss the in-service fall documented in the STRs and post-service diagnosis of renal cyst/7mm non-enhancing. (b.) All findings and conclusions should be supported with a complete rationale and set forth in a legible report, which should reflect the examiner's consideration and analysis of both the medical and lay evidence of record. If it is not possible to provide an opinion without resort to speculation, the reason that is so should be explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge. 8. Return the record to the VA examiner who conducted the June 2019 VA Hip and Thigh Conditions examination. The record and a copy of this Remand must be made available to the examiner. If the examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. (a.) Is it at least as likely as not (50 percent probability or greater) that the Veteran has a left hip disability and a right hip disability that had its onset during active service or within one year of the Veteran's separation from active service, or is otherwise related to service? The examiner is asked to discuss the Veteran's contention that she has a left hip disability and a right hip disability as a result of an in-service fall: (1) fell off a 12 ton truck (2) fell when the ground gave way while marching in basic training. The examiner is also asked to discuss buddy statements of record and the in-service fall documented in the Veteran's STRs. (b.) Is it at least as likely as not that the Veteran's left hip disability and right hip disability was caused or aggravated by her service-connected low back disability? Please address both causation and aggravation separately and explain why or why not. Please discuss the Veteran's contention that she has an altered gait. Please also discuss whether the Veteran's hip pain is related to sciatica associated with her service-connected back disability. (c.) If the examiner finds the Veteran's left hip disability and right hip disability were aggravated by her service-connected low back disability, he/she should attempt to quantify the degree of aggravation beyond the baseline level. (d.) All findings and conclusions should be supported with a complete rationale and set forth in a legible report, which should reflect the examiner's consideration and analysis of both the medical and lay evidence of record. If it is not possible to provide an opinion without resort to speculation, the reason that is so should be explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge. S.C. Krembs Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Smith-Jennings, 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.