Citation Nr: 21005456 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 13-28 153A DATE: February 1, 2021 REMANDED Entitlement to service connection for sinusitis, to include as due to exposure to environmental hazards and/or as due to a qualifying chronic disability pursuant to 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for a right elbow disorder, to include as due to exposure to environmental hazards and/or as due to a qualifying chronic disability pursuant to 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for a left elbow disorder, to include as due to exposure to environmental hazards and/or as due to a qualifying chronic disability pursuant to 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for a gum disorder, to include as due to exposure to environmental hazards and/or as due to a qualifying chronic disability pursuant to 38 C.F.R. § 3.317, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1984 to June 1988 and December 1988 to October 2010, to include service in the Southwest Asia theater of operations during the Persian Gulf War. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in September 2011 by a Department of Veterans Affairs (VA) Regional Office. In April 2018, the Board remanded the issues on appeal, as well as service connection claims for left ventricular hypertrophy, nasal allergies, and hemorrhoids for additional development. A rating decision issued in February 2020 awarded service connection for nasal allergies and left ventricular hypertrophy, while a July 2020 rating decision awarded service connection for hemorrhoids. As such awards constitute complete grants of the benefits sought on appeal, those issues are no longer for appellate consideration. The remaining issues now return for further appellate review. 1. Entitlement to service connection for sinusitis, to include as due to exposure to environmental hazards and/or as due to a qualifying chronic disability pursuant to 38 C.F.R. § 3.317, is remanded. The Veteran contends he has a sinus disorder that began in service as a result of his exposure to environmental hazards during his service in Southwest Asia. See Veteran’s November 2017 Statement. Given the conflicting evidence of record with respect to the existence of a current disability, the Board remanded the claim in April 2018 for additional VA examination. In November 2019, the examiner provided a diagnosis of chronic sinusitis but opined such was less likely than not related to service. The examiner based the opinion on the absence of objective evidence in the service treatment records (STRs), to include a May 2010 report of medical history wherein the Veteran denied a history of sinusitis. Here, the November 2019 VA examiner relied solely upon the fact that the Veteran’s STRs are negative for any complaints, treatment, or diagnosis referable to sinusitis. In addition, the examiner did not address whether the Veteran’s current sinusitis is related to his acknowledged exposure to environmental hazards. Consequently, the Board finds the unfavorable opinion inadequate for the purpose of determining entitlement to service connection and, thus, a remand is warranted for an addendum opinion addressing such matters. 2. Entitlement to service connection for a right elbow disorder, to include as due to exposure to environmental hazards and/or as due to a qualifying chronic disability pursuant to 38 C.F.R. § 3.317, is remanded. 3. Entitlement to service connection for a left elbow disorder, to include as due to exposure to environmental hazards and/or as due to a qualifying chronic disability pursuant to 38 C.F.R. § 3.317, is remanded. The Veteran contends his bilateral elbow disorder is caused by heavy lifting and climbing ladders in service, or in the alternative, by his exposure to environmental hazards while serving in Southwest Asia. See November 2019 VA examination and Veteran’s November 2017 Statement. In this regard, the Veteran’s STRs reflect complaints of elbow pain. In an August 2009 report of medical history, he noted heavy lifting caused pain to his shoulders and elbows. Further, in a May 2010 report of medical history, he stated he had a tingling sensation in both elbows. The medical examiner who reviewed and signed the Veteran’s May 2010 report a month later noted the Veteran’s elbow symptoms had been intermittent for three years but that the Veteran had never requested an evaluation of such condition. The November 2010 VA examination, conducted upon the Veteran’s separation from service, recorded bilateral elbow symptoms, to include tingling to both elbows with heavy lifting and moderate flare-ups of joint disease every two to three weeks. There was bilateral elbow tenderness and some limitation of motion on physical examination. X-ray examination, however, revealed no acute fracture, subluxation, or “significant appearing” degenerative changes affecting the elbows. As a result, the examiner provided a diagnosis of “normal bilateral elbows”; notably, however, in the same statement the examiner indicated the Veteran suffered functional impairment due to joints. Due to such conflicting evidence and the lack of a clearly diagnosed elbow disorder, the Board remanded the Veteran’s claim in April 2018 to afford him additional examination. Specifically, the Board requested that a VA examiner identify any diagnosed elbow disorders dated from November 2010 to the present and whether such was related to the Veteran’s service. If any symptoms were not associated with a known clinical diagnosis, the examiner was to provide an opinion as to whether the Veteran’s bilateral elbow symptoms may be attributed to an undiagnosed illness or whether such symptoms represent a medically unexplained chronic multi-symptom illness (MUCMI). Accordingly, the Veteran underwent such examination in November 2019. At such time, after a review of the file, an interview with the Veteran, and a physical examination, the examiner diagnosed degenerative arthritis of the bilateral elbows. The examiner then opined the Veteran’s bilateral elbow disorder was less likely than not a result of his military service. As rationale, the examiner found the May 2010 complaint of bilateral elbow pain and tingling was acute and there was no evidence of current, chronic, and continuous treatment or care. Upon review, the Board finds this opinion inadequate for adjudication purposes. In this regard, the examiner described the Veteran’s bilateral elbow disorder as acute; however, according to the May 2010 report of medical history, the Veteran’s elbow symptoms had been intermittent for three years. Additionally, VA treatment records reflect complaints of elbow pain. See July 2015 records. Further, the examiner did not discuss the Veteran’s specific contentions that his bilateral elbow symptoms, which began in 2005, are a result of heavy lifting and climbing ladders in service or, in the alternative, related to his exposure to environmental hazards. Finally, given the diagnosis of arthritis, an opinion is necessary to determine whether such manifested within one year of the Veteran’s separation from service. Consequently, the Board finds additional remand is warranted for an addendum opinion addressing such matters. 4. Entitlement to service connection for a gum disorder, to include as due to exposure to environmental hazards and/or as due to a qualifying chronic disability pursuant to 38 C.F.R. § 3.317, is remanded. As an initial matter, the Board notes the Veteran’s dental STRs reflect numerous references to gingivitis and missing teeth. See March 1995 July 1998, July 1999, July 2001, March 2001, September 2002, and December 2006. Further, dental STRs reflect a diagnosis of mild periodontitis in July 1997 and early “perio” in July 1998. On examination in December 2010, the VA examiner found no disease or objective pathology. However, given the Veteran’s reports of gum sensitivity and history of daily pain, the Board remanded the issue to determine the likelihood that such symptoms were attributable to an undiagnosed illness. At such time, the VA examiner, a dentist, noted the Veteran received in-service treatment for gingivitis from 1999 until 2010 and had a history of a diagnosis of gingivitis. He then opined the Veteran did not have periodontitis and thus, the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. Upon review, the Board finds the November 2019 opinion inadequate for adjudication purposes. Although the VA examiner determined the Veteran did not have a diagnosis of periodontitis, the examiner did not address the etiology of the diagnosed gingivitis. Similarly, the examiner did not discuss the etiology of the Veteran’s reported symptoms, to include whether such are attributable to an undiagnosed illness or MUCMI related to in-service exposure to environmental hazards. Therefore, the Board finds a remand is necessary to obtain an addendum opinion addressing such inquiries. The matters are REMANDED for the following actions: 1. Forward the record, to include a copy of this Remand, to the VA clinician who conducted the November 2019 examination, or an appropriate substitute if unavailable, for an addendum opinion addressing the nature and etiology of the Veteran’s sinusitis. After a review of the evidence, the clinician should provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such had its onset in, or is otherwise related to, the Veteran’s military service, to include his exposure to environmental hazards consistent with his service in Southwest Asia. The clinician is advised that the sole basis for a negative opinion may not be the fact that the Veteran’s service treatment records are negative for any complaints, treatment, or diagnosis referable to sinusitis, or evidence of a lack of post-service treatment records demonstrating a continuity of care. A rationale for any opinion offered should be provided. 2. Forward the record, to include a copy of this Remand, to the VA clinician who conducted the November 2019 examination, or an appropriate substitute if unavailable, for an addendum opinion addressing the nature and etiology of the Veteran’s degenerative arthritis of the bilateral elbows. Following a review of the record, the clinician should address the following inquiries: (A) The clinician should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s degenerative arthritis of the bilateral elbows had its onset in, or is otherwise related to, the Veteran’s military service, to include his reports of lifting heavy weights and climbing ladders as well as his in-service exposure to environmental hazards. (B) The clinician also should offer an opinion as to whether any degenerative arthritis of the bilateral elbows manifested within one year of the Veteran’s separation from active duty in October 2010 (i.e., by October 2011). If so, please describe the manifestations. In providing the opinions, the clinician must address the May 2010 report of medical history indicating the Veteran’s elbow symptoms had been intermittent for three years, as well as the post-service VA treatment records reflecting complaints of elbow pain. A rationale for any opinion offered must be provided. 3. Forward the record, to include a copy of this Remand, to the VA clinician who conducted the November 2019 examination, or an appropriate substitute if unavailable, for an addendum opinion addressing the nature and etiology of the Veteran’s claimed gum disorder. Following a review of the record, the clinician should address the following inquiries: (A) For each gum disorder diagnosed during the pendency of the appeal and proximate to the Veteran’s August 2010 claim, to include gingivitis, the clinician shoulder offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such disorder had its onset in, or is otherwise related to, the Veteran’s military service, to include the multiple references to gingivitis, missing teeth, and periodontitis as well as his exposure to environmental hazards. (Continued on the next page)   (B) If any reported symptoms have not been attributed to a known clinical diagnosis, the examiner should indicate whether the Veteran has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that has either (1) existed for 6 months or more, or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period, or whether such symptoms represent a “medically unexplained chronic multisymptom illness.” Such is defined as a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. A rationale should be provided for each opinion offered. M. M. Celli Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. M. Kelly, 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.