Citation Nr: 21015682 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 16-14 558 DATE: March 18, 2021 REMANDED Service connection for multiple sclerosis is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1991 to November 1995. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was before the Board and remanded for further development in November 2019. A Board remand confers on the Veteran, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). Unfortunately, although a medical opinion was obtained, there has not been substantial compliance with the Board’s previous remand directives regarding the issue of multiple sclerosis. 1. Service connection for multiple sclerosis is remanded. The Veteran contends that he had symptoms of multiple sclerosis for years prior to its diagnosis in 2008. January 25, 2014, VA Form 9. Service treatment records demonstrate that the Veteran twice presented with complaints of neck pain, stiffness and decreased range of motion after hitting his head during a fall in Turkey. See July 7, 1995 and August 2, 1995, Chronological Record of Medical Care. The Veteran stated that he could not handle the pressure of both hands on his head. Although the September 1995 separation examination only noted increased cholesterol, the Veteran indicated he had swollen or painful joints when referring to his knees in his final Report of Medical History. In September 1995, after the separation examination, service treatment records further reveal that the Veteran presented with complaints of bilateral cramps in the back of his upper legs for seven days, noting the cramps were worse when sitting and resolved spontaneously. See September 25, 1995, Chronological Record of Medical Care. In a September 2020 medical opinion, the examiner rendered a negative etiology for multiple sclerosis because there was no medical record documentation of symptoms, such as difficulty with balance, during the years prior to the 2008 diagnosis. The examiner opined that the Veteran did not manifest any symptoms of multiple sclerosis while in service or within seven years of separation from service as there was no medical record documentation of related symptoms prior to 2002 and pointed to the September 1995 separation examination as negative for anything suggestive of multiple sclerosis. See September 22, 2020, Medical Opinion. The examiner failed to consider the Veteran’s lay statements concerning symptoms of multiple sclerosis for years prior to the 2008 diagnosis. The examiner did not acknowledge or consider any of the in-service complaints concerning musculoskeletal pain, muscle cramps, and fall. The examiner’s opinions are not supported by adequate reasoning. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (a medical opinion is inadequate if it does not take into account the Veteran’s reports of symptoms and history); Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006) (finding the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (medical opinions based on an incomplete or inaccurate factual premise are not probative). Accordingly, an addendum opinion is necessary. The matters are REMANDED for the following action: 1. Contact the Veteran and request that he provide more information concerning any symptoms of multiple sclerosis he experienced prior to the 2008 diagnosis. Specifically, elicit information regarding the nature of the symptom, the date the symptom began, and the frequency and duration of the symptom. All attempts to secure this information and all information obtained must be documented in and made a part of the claims file. 2. After completing directive #1, obtain an addendum opinion for the September 2020 VA medical opinion from the original examiner. If the original VA examiner is unavailable, a new examiner may be assigned. The examiner should review the virtual file and address the following: (a.) Whether it is at least as likely as not (50 percent or greater probability) that current multiple sclerosis manifested during or is otherwise related to the Veteran’s period of active service. (b.) Whether it is at least as likely as not (50 percent or greater probability) that symptoms of multiple sclerosis manifested prior to November 2002. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. The lack of medical evidence is not an adequate reason for discounting the Veteran’s statements of symptoms of multiple sclerosis. If the examiner rejects the Veteran’s reports of symptoms, he or she must provide a reason for doing so. A rationale for all opinions is to be provided. All pertinent evidence, 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). JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Monica Ball Jackson, 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.