Citation Nr: 21077211 Decision Date: 12/29/21 Archive Date: 12/29/21 DOCKET NO. 18-18 286 DATE: December 29, 2021 REMANDED Entitlement to service connection for residuals of a pineal cyst of the brain is remanded. REASONS FOR REMAND The Veteran served on active duty from June 2009 to December 2015. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In July 2021, the Veteran testified at a virtual hearing conference before the undersigned Veterans Law Judge. A transcript of the hearing is of record. 1. Entitlement to service connection for residuals of a pineal cyst of the brain is remanded. The Veteran claims that she discovered she had a brain cyst/tumor shortly after her separation from service, which she asserts is related to service, to include as due her military occupational specialty (MOS) as a mechanic which exposed her to hazardous material, as well as burn pit exposure and/or an undiagnosed illness. The Veteran's service treatment records document reports of headaches, to include some reports of headaches with nausea, beginning in July 2009 and throughout service until February 2015. The Veteran had the mass removed in December 2016; however, despite the removal, she asserts she continues to experience residuals, to include headaches, loss of smell, memory issues, sleep problems, loss of libido and a scar on the back of her head after removal of the cyst. The Veteran underwent VA examination in connection with her claim in November 2016 and the examiner determined that she did not have a central nervous system condition as review of the evidence shows no findings or diagnosis of a brain tumor. However, the examiner did not account for any residuals and did not address the Veteran's in-service complaints of headaches. As such, the Board finds the opinion to be insufficient. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In addition, in a VA neurosurgery attending note dated July 2017, the chief of neurological surgery indicated that the Veteran's pineal cyst could be congenital or possibly from trauma. In light of the above, the Board finds a new examination and opinion should be obtained upon remand. Updated treatment records should be obtained as well upon remand. The matters are REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated her for his claimed disabilities. After securing any necessary releases, the AOJ should request any relevant records identified. In addition, obtain updated VA treatment records. If any requested records are unavailable, the Veteran and her representative should be notified of such. 2. After records development is completed, the Veteran should be afforded an appropriate VA examination(s) to determine the nature of her residuals of penial cyst of the brain and to obtain an opinion as to whether such are possibly related to service, to include as due to an undiagnosed illness. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted, and the results reported. Following review of the claims file and examination of the Veteran, the examiner should respond to the following: (a.) Does the record reflect that the Veteran undebatably had a penial cyst of the brain that existed prior to her entry into active duty service? Please explain why or why not, to include addressing the in-service May 2010 CT scan of the brain, the July 2017 VA treatment record, and the Veteran's lay statements. See service treatment records, VA treatment records and July 2021 hearing transcript. (b.) If it is undebatable that the Veteran's penial cyst of the brain pre-existed her active duty service, did the condition undergo a permanent worsening during her period of active duty? Please explain why or why not, to include addressing the significance, if any, of the in-service reports of headaches from July 2009 to February 2015 as well as the Veteran's lay statements. See service treatment records as well as the July 2021 hearing transcript. (c.) If the examiner concludes the pre-existing penial cyst was worsened, the examiner should explain whether the worsening was undebatably the result of natural progression rather than the result of activities and/or incidents of active service. Please explain why or why not, to include addressing the in-service reports of headaches as well as the Veteran's lay statements. See service treatment records as well as the July 2021 hearing transcript. (d.) For any pre-existing penial cyst of the brain that was permanently worsened beyond normal progression (aggravated) during service, please opine whether any current penial cyst of the brain, to include residuals thereof is at least as likely as not (50 percent or greater probability) related to that in-service aggravation. Please explain why or why not, to include addressing the significance, if any, of the in-service treatment for headaches as well as the Veteran's lay statements. See service treatment records as well as the July 2021 hearing transcript. (e.) Identify and characterize the Veteran's claimed residual symptoms of headaches, loss of smell, memory issues, sleep problems, and loss of libido as belonging to one of the four disability patterns: i. an undiagnosed illness, ii. a diagnosable but medically unexplained chronic multi-symptom illness (MUCMI) of unknown etiology, iii. a diagnosable chronic multi-symptom illness with a partially understood etiology and pathophysiology, or iv. a disease with a clear and specific etiology. (f.) For a disability for which there is a diagnosis, the examiner must identify: i. the diagnosis. ii. whether the diagnosis has a conclusive, partially understood, or unknown etiology. iii. whether the disease has a conclusive, partially understood, or unknown pathophysiology. (g.) If the examiner determines that the claimed disability has a conclusive etiology, please state what the etiology is and provide the reasoning for the conclusion. (h.) For any penial cyst of the brain that did not pre-exist service and which the examiner determines that the Veteran's disability pattern is either a diagnosable chronic multi-symptom illness with a partially explained etiology OR a disease with a clear and specific etiology and diagnosis, then the examiner should also opine as to whether it is at least as likely as not (50 percent or greater probability) that the condition began in or is caused by service, to include as a result of her exposure to environmental hazards while serving in Southwest Asia, to also include as a result of exposure to hazardous material while performing her duties as a mechanic and/or exposure to burn pits therein. Please explain why or why not, to include addressing the Veteran's contentions. See service treatment records as well as the July 2021 hearing transcript. A detailed rationale for the opinions must be provided. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. If the examiner is unable to offer the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. Jones v. Shinseki, 23 Vet. App. 382 (2010). A. S. CARACCIOLO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Medina 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.