Citation Nr: 21020988 Decision Date: 04/09/21 Archive Date: 04/08/21 DOCKET NO. 15-30 309 DATE: April 9, 2021 REMANDED Entitlement to service connection for chronic right hip degenerative joint disease for accrued benefits purposes is remanded. Entitlement to service connection for chronic left hip degenerative joint disease for accrued benefits purposes, is remanded. Entitlement to service connection for chronic diarrhea for accrued benefits purposes is remanded. Entitlement to service connection for headaches for accrued benefits purposes is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy in November 1973 and in the United States Army from July 1981 to January 1994 including service in Southwest Asia. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a September 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). These issues were previously remanded by the Board in February 2019 in order to obtain any outstanding Social Security Administration records. That remand also addressed the Veteran’s claim for service connection for chronic obstructive pulmonary disease, which has since been granted and is no longer on appeal. Regrettably, the Veteran passed away in September 2020. The RO substituted the Veteran’s surviving spouse (appellant) as the claimant in this appeal. In his March 2021 brief, the appellant’s representative argued that the RO had failed to adequately adjudicate the appellant’s claim by failing to obtain medical opinions addressing the etiology of his conditions. The representative requested additional development to obtain medical opinions for the hips, diarrhea, and headaches. He further requested that the examiner consider the impact of the Veteran’s combat service and the conditions that were service connected prior to his death. The Board finds that remand is warranted to obtain medical opinions that discuss the etiology of the Veteran’s conditions. 1. Entitlement to service connection for chronic right hip degenerative joint disease for accrued benefits purposes The Veteran underwent VA examinations in April 2012 and June 2015 for his hip condition. However, neither examiner provided an opinion as to whether the Veteran’s hip disability was incurred in or caused by his service. Additionally, the Veteran’s November 2011 claim for service connection included the claim of “joint pain.” This symptom is specifically listed as a sign or symptom of an undiagnosed illness and medically unexplained chronic multisymptom illness. 38 C.F.R.§ 3.317(b). No VA examiner has opined whether the Veteran’s joint pain constitutes an undiagnosed illness or medically unexplained chronic multisymptom illness. Therefore, remand is necessary to obtain a medical opinion. 2. Entitlement to service connection for chronic left hip degenerative joint disease with radiation of pain into bilateral thighs (claimed as joint pain) for accrued benefits purposes The Veteran underwent VA examinations in April 2012 and June 2015 for his hip condition. However, neither examiner provided an opinion as to whether the Veteran’s hip disability was incurred in or caused by his service. Additionally, the Veteran’s November 2011 claim for service connection included the claim of “joint pain.” This symptom is specifically listed as a sign or symptom of an undiagnosed illness and medically unexplained chronic multisymptom illness. 38 C.F.R.§ 3.317(b). No VA examiner has opined whether the Veteran’s joint pain constitutes an undiagnosed illness or medically unexplained chronic multisymptom illness. Therefore, remand is necessary to obtain a medical opinion. 3. Entitlement to service connection for chronic diarrhea for accrued benefits purposes The Veteran underwent VA examinations in April 2012 and June 2015 for his diarrhea. However, neither examiner provided an opinion as to whether the Veteran’s chronic diarrhea disability was incurred in or caused by his service. The VA examiners found that there were no diagnosed illnesses for which no etiology was established. However, treatment notes from March 2019 reflect the etiology of the Veteran’s chronic diarrhea was “unclear.” Therefore, remand is necessary to obtain a medical opinion regarding the etiology of the Veteran’s chronic diarrhea, including whether the Veteran’s diarrhea is a functional gastrointestinal disorder that could be considered a medically unexplained chronic multisymptom illness under 38 C.F.R. § 3.317. Additionally, the record reflects the Veteran received treatment from private providers for his diarrhea. For example, a treatment note from March 2019 reflects the VA provider contemplated whether the Veteran’s chronic diarrhea was irritable bowel syndrome (IBS) with diarrhea predominant. The VA provider noted he would ask the Veteran to discuss the trial of a new medication with his non-VA primary care provider and that he was reluctant to start a new medication because the Veteran only went to the VA twice per year. The February 2019 Board remand directed that the RO ask the Veteran to provide the names and addresses of all medical care providers who had recently treated him for his claimed disabilities. After securing any necessary releases, the RO was directed to request any relevant records identified. In October 2019, the RO sent a subsequent development letter to the Veteran requesting he complete an authorization to disclose information to VA and a General Release for Medical Provider Information. A response to this request is not of record. Another attempt should be made to obtain relevant non-VA treatment records pertaining to the Veteran’s treatment for diarrhea. 4. Entitlement to service connection for headaches for accrued benefits purposes. The Veteran underwent VA examinations in April 2012 and June 2015 for his headaches. However, neither examiner provided an opinion as to whether the Veteran’s headache disability was incurred in or caused by his service. Therefore, remand is necessary to obtain a medical opinion. Furthermore, both examiners noted “no” to the question of are there any diagnosed illnesses for which no etiology was established. However, neither examiner provided an explanation for this determination. Considering headaches may be a sign or symptom of an undiagnosed illness or diagnosed medically unexplained chronic multisymptom illness for which a Gulf War Veteran may be presumptively service connected, an addendum opinion is warranted. See 38 C.F.R. § 3.317(b). The matters are REMANDED for the following actions: 1. Ask the appellant to complete a VA Form 21-4142 for physicians and/or facilities where the Veteran was seen for diarrhea, including Dr. D.J. at Digestive Health Associates. Make two requests for the authorized records from any identified provider, unless it is clear after the first request that a second request would be futile. 2. Obtain any relevant VA records that are not included in the file, such as documents that are noted as scanned documents within the records currently available (for example, the April 11, 2014, Non VA Care Consult result note for a screening colonoscopy, which indicates “see scanned document for report”). 3. Obtain opinions from a qualified clinician or clincians on the following: a. Was the Veteran’s joint pain, to include his right and left hip, at least as likely as not incurred in or caused by service? Why or why not? Is it at least as likely as not that the Veteran’s joint pain, to include his right and left hip, constituted an undiagnosed illness? Why or why not? Is it at least as likely as not that the Veteran’s joint pain, to include his right and left hip, constituted a diagnosed medically unexplained chronic multisymptom illness”? Why or why not? The examiner must review the claims file and consider all the relevant evidence, including lay statements. Particular attention is brought to the following: Treatment notes from November 2011 reflect the Veteran reported pain in his anterior thighs and walking causes catch in the right hip area. A 2012 VA examination indicated the Veteran was diagnosed with chronic bilateral hip degenerative joint disease with radiation of pain into bilateral thighs in 2011. At that time, the Veteran reported an onset of gradual, right greater than left, hip pain about six months earlier without a history of trauma. The Veteran underwent a VA examination in June 2015 for hip and thigh conditions. At that time, it was noted he was diagnosed with bilateral arthritis in 2012. The Veteran reported increasing hip pain that began in the 1990s. b. Was the Veteran’s diarrhea at least as likely as not incurred in or caused by his service? Why or why not? Is it at least as likely as not that the Veteran’s reported gastrointestinal symptoms constituted a functional gastrointestinal disorder? Why or why not? The examiner must review the claims file and consider all the relevant evidence, including lay statements. Particular attention is brought to the following: The April 2012 VA examiner noted a diagnosis of chronic diarrhea from 2002 and noted obstipation on radiographic findings. At that time, the Veteran reported a gradual onset getting worse over time with increased frequency. The Veteran had a sigmoidoscopy in Germany in 1988 due to explosive diarrhea while working in a hospital. He reported the test was normal. The Veteran was unable to identify precipitating factors and denied constipation intervals. He experienced symptoms of mild abdominal cramping, flatus, with watery to soft stools about three times a day a minimum of three times a week. In his June 2015 examination, the Veteran reported increasing diarrhea in approximately 1990. The report notes “(? Related to unsanitary environment and eating local food).” It is unclear whether this was a question posed by the examiner, or whether the Veteran himself wondered if this was the cause of his diarrhea at that time. The Veteran further reported two days of solid bowel movements and then one day of liquid stools. The examiner noted the following signs and symptoms: alternating diarrhea and constipation, abdominal distension, and daily cramping. The Veteran’s treatment records reflect he went to the emergency department in October 2011 complaining of eight to nine months of diarrhea. Subsequent treatment records reflect he complained of diarrhea and was referred for a colon screening in January 2014. Treatment notes from April 2014 reflect a screening colonoscopy was completed and a May 2014 abnormal colonoscopy is discussed in August 2014 treatment notes. The Veteran reported in his August 2015 VA Form 9 that he had dealt with chronic diarrhea for years and had a colonoscopy at Digestive Health, which was set up by the VA. He indicated the results were normal with no reason for diarrhea. The onset of his diarrhea was upon his return from Desert Storm in 1991. Treatment notes from March 2019 reflect the Veteran reported chronic diarrhea since the Gulf War. He explained at that time he had multiple evaluations, but no one could tell him the cause. He reported he had a colonoscopy four times. The last gastroenterologist mentioned IBS/diarrhea to him, but no treatment. The appellant provided a January 2021 statement explaining the Veteran suffered constant diarrhea after returning from Iraq in 1991. She explained the Veteran went through a new job every three to four months and each job change was due to his embarrassment from accidents and having to come home and shower and then return to finish his day. He had times he could not leave the house for fear of explosive diarrhea. She believes something in Iraq made her husband ill, be it chemicals, pills he had to take, or the burn pits in Iraq. c. Were the Veteran’s headaches at least as likely as not incurred in or caused by his service? Why or why not? Is it at least as likely as not that the Veteran’s reported headaches constituted a diagnosed medically unexplained chronic multisymptom illness”? Why or why not? Is it at least as likely as not that the Veteran’s reported headaches constituted an undiagnosed illness? Why or why not? The examiner must review the claims file and consider all the relevant evidence, including lay statements. Particular attention is brought to the following: The April 2012 VA examiner noted a diagnosis of tension headaches with a diagnosis of “about 1995-96.” The Veteran reported he had a history of chronic headaches since one to two years after discharge from military service. The Veteran was unable to identify triggers or precipitating factors. His June 2015 VA examination noted a diagnosis of tension headaches in 1992. The Veteran reported after his deployment in 1992, he had increasing stress related headaches. At that time, the Veteran reported sensitivity to light and sound. December 2011 treatment notes indicate a “history of unusual headaches.” The Veteran’s August 2015 VA Form 9 indicates the Veteran ‘s headaches had been ongoing from the 1990s and he saw a VA doctor and was taking Trazadone for nerves, which helped with his headaches. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Vemulapalli, 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.