Citation Nr: 21006528 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 14-20 015A DATE: February 4, 2021 REMANDED Entitlement to service connection for polyarteritis nodosa (PAN) is remanded. Entitlement to service connection for kidney condition, to include as secondary to PAN, is remanded. Entitlement to service connection for a bilateral hip condition, to include as secondary to PAN and kidney condition, is remanded. Entitlement to service connection for a thyroid condition, secondary to PAN, is remanded. Entitlement to service connection for a gastrointestinal condition, secondary to PAN, is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Navy from March 1991 to February 2001. This matter come before the Board of Veterans’ Appeals (Board) on appeal from a December 2010rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In June 2019, the Board remanded the issue for further development. As noted in the prior remand, in the June 2014 Substantive Appeal, the Veteran requested a hearing before the Board at the RO. However, in a statement received by the VA in May 2019, the Veteran stated he would be unable to travel to attend the hearing and 1. Entitlement to service connection for PAN The Board finds that a new examination and etiological opinion is warranted for the Veteran’s claim. The Veteran contends that his PAN is related to service. The Veteran underwent a VA examination in December 2019, in which the examiner opined the Veteran’s PAN is less likely than not incurred in or caused by military service or otherwise causally related to any event or circumstances of his service, including environmental exposures during the Persian Gulf. In support of her opinion, she noted that the Veteran’s PAN was diagnosed in or about 2006/2007, which was several years after discharge from service. The Veteran also appeared for a Gulf War general medical VA examination in December 2019, and the examiner found that there were no symptoms, abnormal findings, or complaints. An addendum opinion was associated with the Veteran’s claim file in September 2020. The examiner reiterated that the Veteran’s PAN was less likely than not related to service in Southwest Asia. She provided that PAN has a clear diagnosis and partially explained etiology as a PAN attack may be triggered by any of several drugs or vaccines or by a reaction to infections (either bacterial or viral), such as strep or staph infections or hepatitis B virus. As such, PAN is not an undiagnosed illness due to exposure to environmental hazards. Furthermore, the Veteran’s service treatment records (STRs) reflect no concerns or suspicions of PAN during service. The examiner also stated that although the exact cause of polyarteritis nodosa is not known, it is clear that an attack may be triggered by any of several drugs or vaccines. The Board finds that the December 2019 and September 2020 opinions are inadequate as neither examiner addressed the Veteran’s contention that his PAN is due to the anthrax vaccine and other vaccines he was forced to take during his time in the Navy. See March 2019 Correspondence. Furthermore, the September 2020 examiner appears to support the theory that the Veteran’s PAN may be due to anthrax vaccine as she stated that a PAN attack may be triggered by any of several drugs or vaccines. Accordingly, remand for a new examination and etiological is warranted. 2. Entitlement to service connection for Kidney condition 3. Entitlement to service connection for Bilateral hip condition 4. Entitlement to service connection for Thyroid condition 5. Entitlement to service connection for Gastrointestinal condition The Veteran contends that his kidney, bilateral hip, thyroid, and gastrointestinal conditions are secondary to his PAN. Therefore, these issues are inextricably intertwined with the issue for entitlement to service connection for PAN. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that claims are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other). Based on the discussion above, the Board will defer adjudication of these issues until the development deemed necessary for the service connection for PAN has been completed. Furthermore, the Board finds that a new examination and etiological opinion is warranted for the issue of service connection for a gastrointestinal condition. A December 2019 VA examiner found that the Veteran does not and has never been diagnosed with an intestinal condition. However, a review of the record indicates that a Dr. M.M.S. noted the Veteran had abdominal pain with gastroesophageal reflux disease (GERD) in a May 2009 private statement. On remand, the VA examiner must consider and address this statement. The matters are REMANDED for the following action: 1. Assist the Veteran in associating with the claim file updated treatment records. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s PAN.  If an in-person examination cannot be provided, consider other appropriate alternatives, such as a telehealth examination. The claim file should be made available to the examiner for review in connection with the examination.  Based on review of the record and conducting an examination of the Veteran, the examiner should respond to the following:  (a.) Obtain a detailed history of the Veteran’s PAN, to include any and all symptomology.  (b.) Determine whether it is at least as likely as not (i.e., at least a 50 percent probability) that the Veteran’s PAN had its onset in or is related to service.  The examiner must specifically discuss the Veteran’s contention that his PAN is related to vaccines received in service to include the anthrax vaccine he took while in service, as well as the September 2020 examiner’s explanation that PAN attacks may be triggered by any of several drugs or vaccines. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinions.  The examiner must provide the rationale for all proffered opinions.  If the examiner is unable to provide any required opinion, he or she should explain why.  If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so.  If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 3. Schedule the Veteran for a VA examination with an appropriate examiner to determine the nature and etiology of the Veteran’s gastrointestinal condition. If an in-person examination cannot be provided, consider other appropriate alternatives, such as a telehealth examination. The claim file should be made available to the examiner for review in connection with the examination. Based on review of the record and conducting an examination of the Veteran, the examiner should respond to the following: (a.) Obtain a detailed history of the Veteran’s gastrointestinal condition, to include any and all symptomology and diagnosis, including GERD.  The examiner must specifically discuss the May 2009 statement from Dr. M.M.S. (b.) The examiner should state whether it is at least as likely as not (i.e., at least a 50 percent probability) that the Veteran’s gastrointestinal condition was caused or aggravated by the Veteran’s PAN. An opinion as to both causation and aggravation is needed. (c.) If the examiner finds that the Veteran’s gastrointestinal condition was aggravated by his PAN, then he/she should specify the baseline level of disability of the gastrointestinal condition prior to aggravation due to the PAN.  Note that aggravation means any incremental increase in disability in the gastrointestinal condition (i.e., any additional impairment of earning capacity) resulting from the PAN. The examiner must provide the rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 4. If upon completion of the above action the issues remain denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. L. Park, 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.