Citation Nr: 21013680 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 14-15 683 DATE: March 10, 2021 REMANDED Entitlement to service connection for Fabry disease is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Navy from September1990 to June1993. During his period of service, the Veteran earned the National Defense Service Medal. In September 2019, the Board remanded the issue of entitlement to service connection for Fabry disease. Specifically, the Board instructed the examiner to address (1) the Veteran’s multiple in-service symptoms that appear to be on the list of symptoms of Fabry disease submitted by the Veteran in October 2009; (2) the theory that recurrent exposure to cold temperatures in service hastened the disease process; and (3) the Veteran’s in-service electrocardiogram recordings demonstrating minimal and moderate voltage criteria for left ventricular hypertrophy (LVH). See September 2019 Board remand directives. The Veteran appeared for a VA central nervous system and neuromuscular diseases examination in January 2020. The examiner opined that the Veteran’s Fabry disease, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by service. In support of the opinion, the examiner explained that the Veteran continued to suffer from the disorder during service, which was typical and not beyond the normal progression for the disorder. The examiner noted that there was no evidence of permanent aggravation beyond normal progression identified. The examiner indicated that the Veteran did not mention concerns upon entrance or upon examination in November 1992. During service, the Veteran reported sinus and allergy symptoms, as well as a neurogenic bladder, which are not signs and symptoms of Fabry disease, as detailed in the list submitted in October 2009. There were no in-service reports of impaired sweating nor cold or heat intolerance during service. An electrocardiography (EKG) conducted in March 1993 revealed moderate left ventricular hypertrophy. A heart murmur was noted at the time of the Veteran’s separation examination in March 1993. The Veteran reported a post-service progression of symptoms, to include suffering strokes and chronic kidney disease. Mild left ventricular hypertrophy, which the VA examiner indicated was an improvement since service, was noted at the time of a December 2011 EKG. Unfortunately, the Board finds that this opinion does not substantially comply with the Board’s September 2019 remand directives. Stegall v. West, 11 Vet. App. 268 (1998); see also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). In this regard, the Board notes that the Veteran’s service treatment records include complaints of or treatment for symptoms that appear on a list of symptoms of Fabry disease submitted by the Veteran in October 2009, specifically exercise-induced reactive airway disease, gastroenteritis, vomiting, diarrhea, bowel syndrome, tingling in hands, and adjustment disorder. However, the examiner failed to address whether these in-service symptoms were typical or evidence of permanent aggravation beyond the condition’s normal progression. Further, although the examiner indicated that there were no in-service reports of cold or heat intolerance, the examiner failed to address the theory that recurrent exposure to cold temperatures in service hastened the disease process. Specifically, the examiner failed to address the Veteran’s May 2017 Board videoconference hearing testimony that he suffers from advanced neurological deficits as a result of his military occupational specialty (MOS), which required going in and out of the freezer. Consequently, the Board finds a remand is warranted to obtain an addendum opinion with a complete rationale that adequately considers the foregoing regarding the nature and etiology of the Veteran’s Fabry disease. The matters are REMANDED for the following action: 1. Obtain a medical opinion from an appropriate medical examiner to determine the nature and etiology of the Veteran’s Fabry disease. The examiner must review pertinent documents in the Veteran’s claims file. It is up the examiner to determine whether an examination is necessary in order to provide the requested opinion. (a.) The examiner must state whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran’s congenital Fabry disease was aggravated by his military service. Clear and unmistakable evidence is evidence that is obvious, manifest, and undebatable. The term “aggravated” in this context refers to a permanent worsening of the underlying condition beyond the natural progress of the disease, as contrasted to temporary or intermittent flare-ups of symptomatology that resolve with a return to the baseline level of disability. If clear and unmistakable evidence is found, the VA examiner should cite to factual data contained in the record or medical literature to support such a conclusion. 1. In providing the opinion, the examiner must address the Veteran’s in-service complaints of or treatment for exercise-induced reactive airway disease, gastroenteritis, vomiting, diarrhea, bowel syndrome, tingling in hands, and adjustment disorder. 2. The examiner must address the Veteran’s contentions that he has advanced neurological deficits due to recurrent exposure to cold temperatures during service, to include going in and out of the freezer as required by his MOS as a mess management specialist. See May 2017 hearing testimony. 3. Lastly, the examiner must address the Veteran’s in-service EKG recordings demonstrating minimal and moderate voltage criteria for LVH. CONTINUED ON NEXT PAGE   Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Joseph, 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.