Citation Nr: 21012705 Decision Date: 03/05/21 Archive Date: 03/05/21 DOCKET NO. 12-01 262 DATE: March 5, 2021 REMANDED Entitlement to service connection for an allergy disorder, to include anaphylaxis, and to include as secondary to service-connected urticaria pigmentosa, is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1969 to September 1971. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2014 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO). This issue was previously before the Board in November 2015, when it was remanded to provide the Veteran with an opportunity for a Board hearing. The Veteran testified before the undersigned Veterans Law Judge in a March 2016 hearing. This issue returned to the Board in July 2016, November 2017, and November 2020, and each time it was remanded for further development. That development was completed, and the case has since been returned to the Board for appellate review. Entitlement to service connection for an allergy disorder, to include anaphylaxis, and to include as secondary to service-connected urticaria, is remanded. Remand is required for substantial compliance with the November 2020 Board remand directives. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. The November 2020 Board remand instructed the RO to add to the claims file any outside treatment records scanned into Vista imaging, and to obtain an addendum VA medical opinion. Records from Vista imaging were successfully added to the claims file in November 2020. The RO obtained an addendum VA medical opinion in December 2020. Remand is required for an addendum VA medical 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). When a Veteran has provided competent lay statements of an in-service injury, the examiner must consider and address them when developing his rationale. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (holding that when the Veteran has provided lay testimony of an in-service injury, an examiner cannot ignore that lay evidence and base his or her opinion that there is no relationship to service on the absence of in-service corroborating medical records). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). In the December 2020 addendum VA medical opinion, the examiner provided a negative nexus opinion. The examiner explained that there is no objective evidence to support a current diagnosis for the claim of allergy disorder. The examiner stated that anaphylaxis is not a chronic respiratory disorder, and it does not require treatment with inhalers, but rather it is an allergic reaction to an allergen. The examiner noted that the Veteran has a history of an allergy to honeybees since childhood, and that it has been a long time since he has been stung by a bee. The examiner stated that service treatment records (STRs) document the bee sting allergy, although it was not documented during induction. The examiner opined that there is no evidence that it was aggravated during service, but failed to provide any supporting rationale. Additionally, the examiner applied the incorrect standard. Every Veteran is presumed to have been in sound condition at entry into service except as to defects, infirmities, or disorder noted at the time of such entry. 38 U.S.C. § 1111 (2012); 38 C.F.R. § 3.304(b) (2019). If not noted on the service entrance examination, in order to rebut the presumption of soundness, it must be shown with clear and unmistakable evidence that a disorder preexisted service and that the disorder was clearly and unmistakably not aggravated by service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Regarding the Veteran’s assertions that the allergy disorder is related to the service-connected urticaria pigmentosa, the examiner also provided a negative nexus opinion. The examiner explained that urticaria pigmentosa is a condition characterized by the presence of too many mast cells in the skin. The examiner stated that the exact cause is unknown, and that it may be a genetic cause in some cases. The examiner explained that the allergy disorder is only caused by honeybee stings, and that no nexus can be established between allergy disorder and urticaria pigmentosa, including aggravation. The examiner explained that being in an environment with honeybees would be the only form of aggravation of the underlying allergy, but that he was not in such an environment during active duty service. However, this contradicts the October 1969 STRs noting an allergic reaction to bee stings, indicating that the Veteran was in an environment with bees. Finally, the November 2020 Board remand instructed the examiner to address the October 1969 STRs, the multiple VA treatment records noting a bee allergy, the August 2014 VA examination, the March 2016 Board hearing testimony, and the lay evidence submitted by the Veteran. Although the examiner stated that they reviewed all available records, and addressed the STRs, they failed to address any of the other records. Accordingly, remand is required for an addendum VA medical opinion. The matters are REMANDED for the following action: Obtain an addendum opinion regarding the etiology of the allergy disorder from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. (a) The examiner must provide an opinion whether it is clear and unmistakable (undebatable) that the Veteran’s allergy disorder existed prior to military service. (b) If so, the examiner must provide an opinion whether it is clear and unmistakable (undebatable) that the Veteran’s allergy disorder was not aggravated by military service. (c) If the answer is that it is not undebatable, then the examiner must provide an opinion regarding whether it is at least likely as not (50 percent or greater probability) that the allergy disorder had its onset in service or is otherwise caused by service. (d) The examiner must also provide an opinion whether it is at least as likely as not (50 percent or greater probability) that the allergy disorder is caused by the service-connected urticaria pigmentosa. (e) The examiner must also provide an opinion whether it is at least as likely as not (50 percent or greater probability) that the allergy disorder is aggravated by the service-connected urticaria pigmentosa. (f) The examiner must address the following: 1) the October 1969 service treatment record noting a bee allergic reaction; 2) the multiple VA treatment records noting a bee allergy; 3) the August 2014 VA examination; 4) the testimony at the March 2016 Board hearing; and 5) the Wikipedia article on anaphylaxis and the EpiPen instructions submitted by the Veteran in April 2015. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Rogos 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.