Citation Nr: 21021372 Decision Date: 04/12/21 Archive Date: 04/12/21 DOCKET NO. 04-32 868 DATE: April 12, 2021 REMANDED Entitlement to service connection for fibromyalgia is remanded. REASONS FOR REMAND The Veteran had active service from May 1975 to December 1976. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2003 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2007, the Veteran testified at a Board hearing. In January 2016, the Board notified the Veteran that the Veterans Law Judge who conducted that hearing was no longer at the Board and that, if the Veteran did not respond to a request for a new hearing within 30 days, the Board would assume that she did not wish to have another hearing. As the Veteran did not respond to that letter, it was presumed that she did not wish to have another Board hearing. In a February 2020 rating decision, the RO granted service connection for arthritis. This is considered a full grant of the benefit sought on appeal and, as such, is no longer before the Board. Unfortunately, the Board had to remand this appeal in September 2007, March 2010, March 2016, June 2017, February 2018, and July 2020. Service Connection for Fibromyalgia The Board regrets the additional delay in remanding the Veteran’s claim again, despite the prior remands. However, it has been settled that the Veteran’s service treatment records are incomplete, which leaves a limited record upon which to decide her appeal. Further, there are inconsistencies in the various examination reports and opinions that must be reconciled before the Board can render a well-informed decision on her claim. Specifically, while private treatment reports and VA treatment records document that she has a history of fibromyalgia, possibly diagnosed as early as 1989 (per her statements), a November 2020 examiner indicated that the Veteran does not have fibromyalgia. Without providing a statement of reasons or adequate rationale, the examiner attributed the Veteran’s symptoms to chronic pain syndrome. After noting that the Veteran has had multiple reports, signs, symptoms, and findings similar to fibromyalgia, the examiner merely stated it is his opinion that those symptoms are due to chronic pain syndrome and not fibromyalgia. As previously stated, the Board is cognizant that this matter stems from a January 2003 rating decision and has been the subject of multiple prior Board remands. However, VA has a duty to assist Veterans in substantiating claims for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A; 38 C.F.R. § 3.159(c). When VA undertakes to provide a VA examination or to obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Here, as the November 2020 medical opinion is inadequate, the Board cannot proceed with the merits of this claim. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (noting that, when the medical evidence of record is insufficient in the opinion of the Board, or of doubtful weight or credibility, the Board must supplement the record by seeking an advisory opinion or ordering a medical examination). The Veteran contends that she has a diagnosis of fibromyalgia that is related to active service. Specifically, she believes that her symptoms began shortly after she arrived at her duty station on Midway Island in January 1976. She states that she felt that she had influenza but no fever, and that she had severe muscle pain, fatigue, insomnia, urinary frequency, difficulty concentrating and remembering instructions, jaw pain, and severe headaches. See May 2016 Lay Statement from Veteran. A June 2013 VA treatment note documents an assessment for “polyarthralgia/fibromyalgia: neck, back, knees, and ankle pain, 3-5/10,” which seemingly ties several service-connected disabilities to her diagnosed fibromyalgia. The medical evidence indicates that the Veteran was diagnosed with fibromyalgia in 1989 and has had associated symptoms since then. In July 2005, she reported to a physical therapist that she was diagnosed with fibromyalgia in 1989. See July 2005 Private Treatment Note. Similarly, a December 2001 letter from a private treatment provider supports a possible diagnosis of fibromyalgia prior to 2004, as the letter states that “diagnoses brought forward to this office include but are not limited to: degenerative disc disease, arthropathy, fibromyalgia, chondromalacia, and carpal tunnel.” See December 27, 2001 Private Treatment Letter. Also, a January 2021 rating decision granted service connection for a somatic symptom disorder, based on a January 2021 VA examination report for mental disorders. The specific diagnosis is somatic symptom disorder, with predominant pain. See January 2021 VA Examination Report for Mental Disorders. However, this examination report does not account for all the symptoms attributable to her fibromyalgia. The symptoms documented on the report are chronic sleep impairment, mild memory loss, and disturbances of mood and motivation. On the November 2020 VA examination report for fibromyalgia, the examiner indicated that the Veteran does not have fibromyalgia, but then included a list of symptoms attributable to fibromyalgia, including widespread musculoskeletal pain, stiffness, muscle weakness, fatigue, sleep disturbances, and anxiety. As previously stated, the Veteran had also discussed having urinary frequency, difficulty concentrating and remembering instructions, jaw pain, and severe headaches, which she claims are related to her fibromyalgia. She is also service-connected for several musculoskeletal disabilities, from which she experiences pain, including degenerative arthritis of the right hand and right thumb, right knee osteoarthritis, left ankle lateral collateral ligament sprain, right lateral collateral ligament sprain, degenerative joint disease of the left knee, impairment of the left thigh, lumbar spine degenerative disc disease, and limitation of flexion of the left thigh. Accordingly, the Board finds that a supplemental medical opinion is needed to reconcile the VA reports and medical opinions. Governing law provides that the evaluation of the same manifestation under different diagnoses, known as pyramiding, is to be avoided. See Esteban v. Brown, 6 Vet. App. 259 (1994); see also 38 C.F.R. § 4.14. A medical opinion should be obtained to clarify whether the Veteran has a current diagnosis of fibromyalgia related to service, and whether the symptoms of fibromyalgia are distinct from those of the above service-connected disabilities. Accordingly, this matter is REMANDED for the following action: Obtain an appropriate supplemental medical opinion from a different VA clinician (other than the January 2021 VA examiner) as to the etiology of any fibromyalgia the Veteran may have. The examiner must fully review the claims file, including the various medical opinion reports, the January 2021 VA mental disorders examination report that diagnosed somatic symptom disorder with predominant pain, and the November 2020 fibromyalgia DBQ. The examiner is asked to reconcile these reports and respond to the following: (a.) Opine as to whether the Veteran has current symptoms of fibromyalgia that are separate manifestations from the symptoms of the already service-connected somatic symptom disorder, degenerative arthritis of the right hand and right thumb, right knee osteoarthritis, left ankle lateral collateral ligament sprain, right lateral collateral ligament sprain, degenerative joint disease of the left knee, impairment of the left thigh, lumbar spine degenerative disc disease, and limitation of flexion of the left thigh disabilities. (b.) Opine as to whether any diagnosed fibromyalgia is at least as likely as not (50 percent or greater probability) related to an in-service injury, event, or disease. (c.) Opine as to whether any diagnosed fibromyalgia is at least as likely as not (50 percent or greater probability) proximately due to, or aggravated (made worse) beyond its natural progression by, a service-connected disability. A complete rationale must be provided for all opinions expressed. THERESA M. CATINO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Trowers, 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.