Citation Nr: 21010950 Decision Date: 02/26/21 Archive Date: 02/26/21 DOCKET NO. 12-33 396 DATE: February 26, 2021 REMANDED Entitlement to service connection for a neurological disorder with history of stroke or transient ischemic attack (TIA), to include as due to a chronic qualifying disability is remanded. Entitlement to service connection for migraine headaches, to include as due to a neurological disorder, to include as due to a chronic qualifying disability is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1990 to February 1992, with verified service in Southwest Asia from January 1991 to April 1991. In December 2015, the Veteran appeared at a Board hearing and testified before the undersigned Veterans Law Judge. The Board remanded the above-mentioned issues in January 2020 for further evidentiary development. 1. Entitlement to service connection for a neurological disorder with history of stroke or transient ischemic attack (TIA), to include as due to a chronic qualifying disability is remanded. Though the Board regrets additional delay, remand is required for an adequate VA addendum opinion. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran was diagnosed with Moyamoya disease by a neurosurgeon in 2011. In a September 2012 VA examination, the examiner stated that the Veteran had a diagnosable chronic multi symptom illness with partially explained etiology. This opinion was deemed inadequate, however, for lack of rationale. In the April 2016 VA examination, the examiner related all of the Veteran’s neurological symptoms to Moyamoya disease. In a July 2019 VA examination, the examiner stated that the etiology of Moyamoya disease was unknown and noted that there was a genetic component to the disease, with most incidence of diagnosis being amongst people of Asian descent. In the October 2020 VA examination, the examiner again attributed all of the Veteran’s neurological symptoms to Moyamoya disease and stated that the etiology of Moyamoya disease was unknown, although some genetic associations had been identified. The Board finds that a supplemental medical opinion is needed as to whether the Veteran's Moyamoya disease may be considered a medically unexplained chronic multisymptom illness (MUCMI). A medically unexplained chronic multisymptom illness means 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. 38 C.F.R. § 3.317(a)(2)(i)(B). Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained (such as diabetes or multiple sclerosis). Several examiners have stated that the etiology of the disease is largely unknown and so an additional opinion must be obtained to determine whether the Veteran’s Moyamoya disease is considered an MUCMI. 2. Entitlement to service connection for migraine headaches, to include as due to a neurological disorder, to include as due to a chronic qualifying disability is remanded. The Board finds that the issue of entitlement to service connection for migraine headaches is inextricably intertwined with the remanded service connection claim. The examiners from the April 2016 and October 2020 VA examinations and a March 2018 private physician letter related the Veteran’s headaches to the Veteran’s Moyamoya disease. As development of the Veteran’s claim for service connection for a neurological disorder may affect the Veteran’s claim for a headache condition, remand is required. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that issues are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other). The matters are REMANDED for the following action: 1. Obtain a medical opinion to determine the nature and etiology of any neurological disorder(s), to include Moyamoya disease. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, one must be provided. A well-reasoned rationale and explanation for all opinions expressed must be provided. The examiner is asked to answer the following: Is Moyamoya disease 1) an undiagnosed illness, or 2) a medically unexplained chronic multi-symptom illness defined by a cluster of signs or symptoms, including 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 address: 1) the December 2020 VA examination; 2) the July 2019 VA Medical Opinion; 3) the January 2018 VHA opinion; 4) the March 2018 VHA addendum opinion; 5) the 2016 VA examinations and opinions; 6) the Veteran’s service treatment records; 7) all relevant private and VA treatment records; and 8) the Veteran’s lay statement of records. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Ashley Ki 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.