Citation Nr: 21012965 Decision Date: 03/08/21 Archive Date: 03/08/21 DOCKET NO. 15-01 464 DATE: March 8, 2021 REMANDED Entitlement to service connection for a fatigue disorder, to include as due to exposure to environmental hazards, an undiagnosed illness, or a medically unexplained chronic multisymptom illness (MUCMI), is remanded. Entitlement to service connection for gastrointestinal symptoms, other than irritable bowel syndrome (claimed as gastroesophageal reflux disease and gastric ulcers), to include as due to exposure to environmental hazards, an undiagnosed illness, or a MUCMI, is remanded. Entitlement to service connection for migraine headaches, to include as due to exposure to environmental hazards, an undiagnosed illness, or a MUCMI, is remanded. Entitlement to service connection for a left eye disability, to include as due to exposure to environmental hazards, is remanded. Entitlement to service connection for a right eye disability, to include as due to exposure to environmental hazards, or as secondary to a left eye disability, is remanded. REASONS FOR REMAND The Veteran had active service from September 1984 to July 1987 and October 1987 to October 1991, with additional service in the Reserves. He had service in Southwest Asia from December 1990 to May 1991. This matter comes before the Board of Veterans’ Appeals (BVA or Board) from July 2012, January 2014, and September 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran requested a hearing before the Board. The requested hearing was conducted in October 2015 by the undersigned Veterans Law Judge. A transcript is associated with the claims file. In July 2018, the Board remanded these claims for additional development. 1. Entitlement to service connection for a fatigue disorder, to include as due to exposure to environmental hazards, an undiagnosed illness, or a MUCMI. 2. Entitlement to service connection for gastrointestinal symptoms, other than irritable bowel syndrome (claimed as gastroesophageal reflux disease (GERD) and gastric ulcers), to include as due to exposure to environmental hazards, an undiagnosed illness, or a MUCMI. 3. Entitlement to service connection for migraine headaches, to include as due to exposure to environmental hazards, an undiagnosed illness, or a MUCMI. The Veteran seeks entitlement to service connection for disabilities manifested by fatigue, gastrointestinal symptoms claimed as GERD and gastric ulcers, and migraines. The Veteran asserts these symptoms began during service and are either due to exposure to environmental hazards while serving near burn pits, an undiagnosed illness or are all part of a MUCMI. The Veteran was previously afforded VA examinations for fatigue, gastrointestinal symptoms claimed as GERD and ulcers, and migraines, in March 2020, at which time the VA examiner indicated the Veteran did not have a diagnosis of chronic fatigue syndrome or chronic GERD, although he had subjective symptoms. Of note, an April 2013 VA examination diagnosed the Veteran with GERD and opined that his fatigue was likely due to interrupted sleep from reflux. Regarding the Veteran’s headaches, the Board notes that the Veteran had a documented closed head injury in September 1988. To date, a medical opinion has not been obtained as to whether the Veteran’s claimed headaches are causally or etiologically due to his head injury during service. On remand, the Board finds addendum opinions are necessary that clarify whether the Veteran has a diagnosis of a fatigue disorder and GERD and whether these claimed disabilities are causally or etiologically due to an undiagnosed illness, his exposure to burn pits, or are part of a MUCMI. Additionally, a medical opinion is necessary regarding the etiology of the Veteran’s headaches. 4. Entitlement to service connection for a left eye disability, to include as due to exposure to environmental hazards. 5. Entitlement to service connection for a right eye disability, to include as due to exposure to environmental hazards or as secondary to a left eye disability. The Veteran seeks entitlement to service connection for left and right eye disabilities. As noted in the prior Board remand, in July 2018, these claims have a complicated procedural history. The Veteran originally claimed a right eye disability in October 2011 and then a bilateral eye disability in March 2013. During his October 2015 Board hearing, the Veteran testified about both his left and right eyes, and indicated that he was informed by a physician that due to the problems in his left eye, a strain was placed on his right eye, resulting in right eye problems. The Veteran asserts that he had two eye injuries during service, a possible eye fracture and that his eye was poked and scratched while playing football. The Veteran was afforded a VA examination in June 2012 and March 2020. Both VA examiners stated that the Veteran’s service treatment records were silent as to any eye injuries, except by historical record. The examiners then offered negative opinions. Importantly, service treatment records document a left eye injury in September 1988, with a noted closed head trauma, possible fracture, and he was placed on a profile and given drops for his left eye. A medical opinion based on an inaccurate factual premise has limited, if any, probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Therefore, these issues are remanded to obtain addendum opinions. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all updated treatment records. 2. Obtain an addendum VA medical opinion for the Veteran’s claimed fatigue disorder. If deemed necessary by the examiner, afford the Veteran a VA examination. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. Based on a full review of the record, to include the Veteran’s lay statements regarding the incurrence and symptomatology of his disorder, please answer the following: a) The examiner should specifically state whether the Veteran’s fatigue is attributed to a known clinical diagnosis. If so, please specify each such diagnosis. (b) If the Veteran’s fatigue has not been determined to be associated with a known clinical diagnosis, the examiner should indicate whether the Veteran has objective indications of a chronic disability resulting from a medically unexplained chronic multisymptom 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. (c) For each diagnosed fatigue disorder, please opine whether it is at least as likely as not (i.e., probability of 50 percent) that the diagnosed disorder manifested during service or is causally or etiologically due to service, to include exposure to environmental hazards during service. The Veteran’s lay statements regarding his history must be fully considered and discussed when formulating an opinion. The examiner must offer comments on the Veteran’s asserted theory that his fatigue is due to exposure to environmental hazards to include burn pits, as due to an undiagnosed illness, or is part of a medically unexplained chronic multisymptom illness due to his service in Southwest Asia. In providing these opinions, the examiner must acknowledge and discuss any lay evidence of a continuity of symptomatology. All opinions must be supported by a clear rationale and include a discussion of the facts and medical principles involved. 3. Obtain an addendum VA medical opinion for the Veteran’s claimed GERD/gastric ulcers. If deemed necessary by the examiner, afford the Veteran a VA examination. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. Based on a full review of the record, to include the Veteran’s lay statements regarding the incurrence and symptomatology of his disorder, please answer the following: a) The examiner should specifically state whether the Veteran’s gastrointestinal symptoms, claimed as GERD/gastric ulcers are attributed to a known clinical diagnosis. If so, please specify each such diagnosis. The examiner should consider and discuss the April 2013 VA examination diagnosing GERD and the March 2020 VA examination stating there was “no data for a GERD” diagnosis shown. (b) If the Veteran’s gastrointestinal symptoms have not been determined to be associated with a known clinical diagnosis, the examiner should indicate whether the Veteran has objective indications of a chronic disability resulting from a medically unexplained chronic multisymptom 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. (c) For each diagnosed gastrointestinal disorder, please opine whether it is at least as likely as not (i.e., probability of 50 percent) that the diagnosed disorder manifested during service or is causally or etiologically due to service, to include exposure to environmental hazards during service. The Veteran’s lay statements regarding his history must be fully considered and discussed when formulating an opinion. The examiner must offer comments on the Veteran’s asserted theory that his gastrointestinal symptoms are due to exposure to environmental hazards to include burn pits, as due to an undiagnosed illness, or is part of a medically unexplained chronic multisymptom illness due to his service in Southwest Asia. In providing these opinions, the examiner must acknowledge and discuss any lay evidence of a continuity of symptomatology. All opinions must be supported by a clear rationale and include a discussion of the facts and medical principles involved. 4. Obtain an addendum VA medical opinion for migraines. If deemed necessary by the examiner, afford the Veteran a VA examination. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. Based on a full review of the record, to include the Veteran’s lay statements regarding the incurrence and symptomatology of his disorder, please answer the following: a) The examiner should specifically state whether the Veteran’s headaches are attributed to a known clinical diagnosis. If so, please specify each such diagnosis. (b) If the Veteran’s headaches have not been determined to be associated with a known clinical diagnosis, the examiner should indicate whether the Veteran has objective indications of a chronic disability resulting from a medically unexplained chronic multisymptom 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. (c) For each diagnosed headache disorder, please opine whether it is at least as likely as not (i.e., probability of 50 percent) that the diagnosed disorder manifested during service or is causally or etiologically due to service, to include the documented closed head trauma in September 1988, and/or exposure to environmental hazards during service. The Veteran’s lay statements regarding his history must be fully considered and discussed when formulating an opinion. The examiner must offer comments on the Veteran’s asserted theory that his headaches are due to exposure to environmental hazards to include burn pits, as due to an undiagnosed illness, or is part of a medically unexplained chronic multisymptom illness due to his service in Southwest Asia. In providing these opinions, the examiner must acknowledge and discuss any lay evidence of a continuity of symptomatology. All opinions must be supported by a clear rationale and include a discussion of the facts and medical principles involved. 5. Obtain an addendum VA medical opinion for the Veteran’s claimed left and right eye disabilities. If deemed necessary by the examiner, afford the Veteran a VA examination. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. Based on a full review of the record, to include the Veteran’s lay statements regarding the incurrence and symptomatology of his disorder, the examiner should offer comments and an opinion addressing whether it is at least as likely as not (50 percent probability or greater): i.) that any currently diagnosed right or left eye disorder had its onset in service or is otherwise attributable to service, to include the documented left eye injury during service in September 1988, the asserted right eye injury during service, and/or exposure to environmental hazards during service? ii.) that any currently diagnosed right eye disorder is proximately due to or aggravated (beyond a natural progression) by a left eye disorder? *The examiner must offer comments and an opinion on the documented September 1988 left eye injury and the Veteran’s contentions that his eyes were injured during service causing his current eye disorders, and that strain on his right eye from the in-service left eye injury caused his current right eye disorders. *The examiner should also offer comments on the September 2016 opinion from Dr. S. opining that the Veteran’s right eye scar is consistent with a retinal scratch he received during service. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Andersen, 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.