Citation Nr: 21009504 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 06-22 539 DATE: February 22, 2021 REMANDED Entitlement to service connection for pulmonary embolism, to include as due to Gulf War Syndrome and as secondary to service-connected disabilities, is remanded. Entitlement to service connection for acute microscopic hematuria (claimed as kidney problems, blood in urine, and pyelonephritis), to include as due to Gulf War Syndrome and as secondary to service-connected disabilities, is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1978 to June 1998. These matters are before the Board of Veterans’ Appeals (Board) on appeal from April 2014 and November 2015 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). This case was most recently before the Board in September 2018, at which time it was remanded for further development, as discussed below. The Board finds that the remand directives were not substantially complied with and thus another remand is warranted. Stegall v. West, 11 Vet. App. 268, 271 (1998). In September 2018, the Board also remanded the issue of entitlement to a rating in excess of 20 percent for IVDS of the cervical spine for a statement of the case. In November 2020, the RO issue a statement of the case and the Veteran perfected an appeal in the legacy system with the submission of a VA Form 9 later that month. The Board separately docket this appeal (as it only had limited jurisdiction in September 2018) and it will be the subject of a later, separate Board decision. 1. Entitlement to service connection for pulmonary embolism, to include as due to Gulf War Syndrome and as secondary to service-connected disabilities, is remanded. A September 2018 Board decision remanded the claim of service connection for pulmonary embolism and directed the AOJ to obtain a VA medical opinion to determine whether the Veteran’s pulmonary embolism is related to exposure to contaminants at Camp Lejeune or secondary to his service-connected disabilities. 09/20/2018, BVA Decision. A July 2019 VA examination noted the diagnosis of pulmonary vascular disease, including pulmonary thromboembolism, specifying confirmed diagnoses of pulmonary embolism in December 1998 and February 2013. The examiner also indicated that the Veteran developed deep vein thrombosis in the early 1990s, which is during the Veteran’s period of active service. The examiner opined that the Veteran’s pulmonary embolism is less likely than not related to exposure to contaminants at Camp Lejeune or secondary to his service-connected disabilities. Specifically, the examiner indicated that the etiology of the Veteran’s pulmonary embolism is known, having been caused by deep vein thrombosis in the left leg. Additionally, the examiner remarked that one occurrence of deep vein thrombosis puts the Veteran at greater risk of future deep vein thrombosis, which causes pulmonary embolism. 08/23/2019, C&P Exam. After reviewing the development obtained on remand, the Board finds that the remand directives were not substantially complied with and, therefore, another remand is warranted. Stegall, 11 Vet. App. at 271. Specifically, the examiner did not provide an opinion as to whether the Veteran’s current pulmonary embolism is at least as likely as not related to his development of a deep vein thrombosis during active service. Accordingly, the Board finds the July 2019 VA examination to be incomplete, and that an addendum medical opinion is warranted. 2. Entitlement to service connection for acute microscopic hematuria, to include as due to Gulf War Syndrome and as secondary to service-connected disabilities, is remanded. A September 2018 Board decision remanded the claim of service connection for acute microscopic hematuria and directed the AOJ to schedule a VA examination to determine whether the condition is related to service, to include Gulf War Syndrome, exposure to contaminants at Camp Lejeune, or secondary to his service-connected disabilities. 09/20/2018, BVA Decision. A July 2019 VA examiner opined that the Veteran’s microscopic hematuria is less likely than not related to Gulf War Syndrome or exposure to contaminants at Camp Lejeune. Specifically, the examiner indicated that hematuria is not a diagnosis and merely a physical sign. The examiner noted medical records reporting that the Veteran may have benign familial hematuria and remarked that the Veteran needs a workup to determine the etiology of this clinical sign. The examiner also opined that the Veteran’s microscopic hematuria is less likely than not proximately due to or aggravated by a service-connected disability. Specifically, the examiner indicated that the Veteran’s microhematuria is acute and not chronic, and that the Veteran’s service-connected disabilities have no pathophysiological relationship to hematuria. Again, the examiner recommended that the Veteran undergo a diagnostic workup to determine the etiology of his hematuria condition. 08/23/2019, C&P Exam. As such, the Board finds that the remand directives were not substantially complied with and, therefore, another remand is warranted. Stegall, 11 Vet. App. at 271. Specifically, examiner was unable to provide an opinion regarding the etiology of the Veteran’s microscopic hematuria without a diagnostic workup for the condition. Accordingly, the Board finds the July 2019 VA examination to be incomplete and that the Veteran should be afforded the necessary diagnostic workup, after which an addendum medical opinion is warranted.   3. Entitlement to TDIU is remanded. The Board finds that the claim of entitlement to TDIU is inextricably intertwined with the Veteran’s claims for service connection for pulmonary embolism and acute microscopic hematuria. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (stating that two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). As such, TDIU is also remanded to the AOJ. These matters are REMANDED for the following actions: 1. Obtain any outstanding VA treatment records. Additionally, request the Veteran to submit any relevant private treatment reports or provide VA with authorization to obtain any such records. 2. Afford the Veteran a diagnostic workup to determine the etiology of his hematuria condition. See 08/23/2019, C&P Exam. 3. After completing directive # 1, obtain an addendum opinion from an appropriate clinician to determine the nature and etiology of pulmonary embolism. An in-person examination is not required unless deemed necessary by the clinician. The clinician is to review the virtual file, including a copy of this Remand. The clinician is to address the following: (a.) Whether it is at least as likely as not (probability of 50 percent or greater) that his current pulmonary embolism was incurred in and/or related to his period of active service, to include his development of a deep vein thrombosis during active service. A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). 4. After completing directives # 1 and 2, obtain an addendum opinion from an appropriate clinician to determine the nature and etiology of acute microscopic hematuria. An in-person examination is not required unless deemed necessary by the clinician. The clinician is to review the virtual file, including a copy of this Remand. The clinician is to address the following: (a.) Whether it is at least as likely as not (probability of 50 percent or greater) that his current acute microscopic hematuria was incurred in and/or related to his period of active service. (b.) Whether it is at least as likely as not (probability of 50 percent or greater) that his acute microscopic hematuria or any diagnosed kidney disability is related or attributable to his military service, to include exposure to contaminated water at Camp Lejeune, or exposure to chemicals while serving in Kuwait. (c.) Whether it is at least as likely as not (probability of 50 percent or greater) that his acute microscopic hematuria or any diagnosed kidney disability is caused by a service-connected disability. (d.) Whether it is at least as likely as not (probability of 50 percent or greater) that his acute microscopic hematuria or any diagnosed kidney disability was aggravated (that is, any increase in severity beyond the natural progress of the condition as shown by comparing the current disability to medical evidence created prior to any aggravation) by a service-connected disability. (e.) Whether the Veteran has objective indications, as established by history, physical examination, and laboratory tests, of an undiagnosed illness or a medically unexplained chronic multi-symptom illness, manifested by acute microscopic hematuria or other kidney related symptoms that has existed for six months or more or exhibited intermittent episodes of improvement and worsening over a six-month period. (f.) A “medically unexplained chronic multi-symptom illness” 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. The examiner must provide an opinion as to the etiology of the Veteran’s acute microscopic hematuria.   A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board David Han 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.