Citation Nr: 21021426 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 16-15 810A DATE: April 13, 2021 REMANDED Entitlement to a rating in excess of 10 percent for allergic urticaria with anaphylaxis is remanded. Entitlement to service connection for a right knee disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from December 2002 to October 2006. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from January 2014 and March 2014 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). In July 2020, the Board remanded the matters for additional development. 1. Entitlement to a rating in excess of 10 percent for allergic urticaria with anaphylaxis is remanded. In the July 2020 remand, the Board directed the RO to schedule the Veteran for an examination to fully assess the severity of her service-connected urticaria with anaphylaxis. The Board specifically directed the examiner to determine at which points during the appeal period (since August 2013) the Veteran has used immunosuppressive therapy, second line treatments, and third line treatments to treat her allergic urticaria. In October 2020, the Veteran underwent a VA skin diseases examination. The examiner diagnosed the Veteran with allergic urticaria with anaphylaxis and noted that she has never had to use her epi-pen to treat her condition. The examiner opined that there was no evidence to suggest that the Veteran’s allergic urticaria with anaphylaxis had increased in severity and that she had never sought treatment for the condition. In October 2020, after the VA skin examination, the Veteran’s attorney submitted a statement contending that the examination was inadequate. The attorney noted that the purpose of the examination was to determine the medications prescribed to the Veteran for the entire appellate period and that her treatment records reflect that she receives annual injections and has taken multiple medications. In November 2020, the examiner provided an addendum opinion regarding the Veteran’s urticaria. The examiner stated that the Veteran reported that the only medication she used for the condition was an epi-pen. There was no further discussion of medications the Veteran used during the entire appeal period. The claims file does reflect that the Veteran has used several medications to treat her urticaria with anaphylaxis during the period on appeal. An April 2015 treatment note indicates that the Veteran was provided Triamcinolone Aceto Cream and Hydroxyzine for her anaphylaxis. See Mar. 2016 CAPRI, p. 39. A June 2015 treatment notes indicates that the Veteran ordered Benadryl and Zyrtec from VA to treat the condition. See Jun. 2017 CAPRI, p. 14. In an October 2016 correspondence to her VA provider, the Veteran stated that her medication does not always work and that her anaphylaxis was not controlled. See Jun. 2018 CAPRI, p. 145. A March 2017 private treatment note indicated that the Veteran’s current medications included Albuterol, Singulair, Zyrtec, and Famotidine, which was prescribed “as needed for heartburn or hives.” See Mar. 2017 Medical Treatment Record – Non-Government Facility. On this date, the Veteran was also prescribed Carbinoxamine Maleate and Fluticasone. Id. A March 2019 VA record reflects several outpatient medications for the Veteran, including Albuterol, Diphenhydramine, Epinephrine, Fexofenadine, Fluticasone, and Montelukast. See Mar. 2019 Medical Treatment Record – Government Facility, p. 3. In a December 2019 VA skin diseases examination, the examiner noted that the Veteran used clobetasol cream to treat her urticaria. See Dec. 2019 C&P Examination, p. 4. The Board finds that both the October 2020 examination and November 2020 addendum opinion are wholly inadequate for their failure to comply with the July 2020 Board remand to address the Veteran’s treatment for urticaria throughout the entire appeal period. It appears that the examiner focused only on treatment for the condition for the 12 months preceding the examination and addendum opinion. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (finding that a Board remand confers on a claimant the right to compliance with the remand orders). Thus, the Board finds that a new examination is required. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes to provide a medical examination or opinion, it must ensure that the examination or opinion is adequate). 2. Entitlement to service connection for a right knee disability is remanded. In the July 2020 remand, the Board directed the RO to obtain a new VA examination for the Veteran’s right knee disability. The Board directed the examiner to opine whether the Veteran’s right knee disability was incurred in, caused by, or otherwise related to her active service. The examiner also was directed to opine whether the disability was caused by or aggravated by her service-connected degenerative disc disease of the thoracic spine. The Board further directed the examiner to consider the Veteran’s statements regarding her work as a medic during active service. She stated that in the course of her duties, she was required to lift individuals who were heavier than her either by litter or over her back. See Apr. 2016 VA Form 9; Feb. 2017 Correspondence. She contends that these activities injured her knee. In October 2020, the Veteran underwent a VA knee and lower leg conditions examination by M.R. M.R. diagnosed the Veteran with right knee strain with a date of diagnosis of 2004 and degenerative arthritis of the right knee with a date of diagnosis of 2019. M.R. opined that it was less likely than not that the Veteran’s right knee condition was incurred in or caused by her active duty service. Regarding rationale, the examiner noted, “I have considered the Veteran’s statements of service duties as a medic. There is no evidence that Veteran suffered from knee injury or pain during military service.” M.R. also stated that medical literature does not support a relationship between right knee strain and degenerative disc disease of the thoracic spine. The examiner further noted that knee strains occur when a tendon or muscle in the knee is damaged, often from overuse or a sudden dramatic increased of use of the knees. The examiner also provided common causes of knee sprains. Regarding secondary service connection, the examiner simply stated medical literature does not support a relationship between right knee strain and degenerative disc disease of the thoracic spine. In October 2020, after the examination, the Veteran’s attorney contended that the October 2020 VA knee examination was inadequate. She noted the examiner’s statement that knee strain is often caused by overuse, which she contended is consistent with the Veteran’s reports of in-service “wear and tear” of the knee. The attorney also noted that the Veteran was diagnosed with knee strain, but the examiner provided information regarding knee sprains in the opinion. In November 2020, M.R. provided an addendum opinion regarding the Veteran’s right knee disability. M.R. stated that medical literature does not support a relationship between right knee strain aggravation by degenerative disc disease of the thoracic spine. There was no further opinion or rationale offered by this addendum. On the same date, another examiner, J.G., provided a partial addendum opinion to the October 2020 knee examination. J.G. noted that the previous medical opinion should be disregarded. J.G. opined that it was less likely than not that the Veteran’s right knee condition was aggravated beyond its natural progression by her service-connected degenerative disc disease of the thoracic spine. The Board finds the October 2020 knee examination and November 2020 addendum opinions to be inadequate for multiple reasons. First, only the October 2020 examination provides a medical opinion regarding direct service connection. The Board finds this opinion inadequate because it failed to address the Veteran’s contentions regarding how her in-service duties as a medic affected her knee. The examiner stated that the Veteran’s contentions were considered, but failed to sufficiently address how they relate to the examiner’s statement that knee strain occurs when a tendon or muscle in the knee is damaged, often from overuse or a sudden dramatic increased of use of the knees. Regarding secondary service connection, there were two separate addendums addressing this issue. The addendum opinion by M.R. simply stated that medical literature does not support a relationship between right knee strain aggravation by degenerative disc disease of the thoracic spine. There was no citation to actual medical literature to support the conclusion; there was only a citation to a website explaining how to avoid knee pain flare-ups. The Board finds this opinion inadequate as the examiner’s opinion was conclusory and based upon medical literature without citation to appropriate literature. The addendum opinion by J.G. only provides an opinion regarding whether the Veteran’s right knee condition was aggravated by her back condition, not whether it was caused by her back condition. This opinion failed to comply with the directives of the July 2020 remand, which requested a secondary service connection opinion regarding both causation and aggravation. For the reasons listed above, the Board finds that the October 2020 examination and both November 2020 addendum opinions are inadequate for adjudication purposes. Thus, the claim must be remanded in order to obtain an adequate examination and opinion. See Barr, supra; Stegall, supra. The matters are REMANDED for the following actions: 1. Schedule the Veteran for an examination with an examiner other than the October and November 2020 examiners to ascertain the etiology of her right knee disability. Any indicated evaluations, studies or tests deemed necessary should be accomplished. The entire claims file, to include a complete copy of this REMAND, should be made available to the examiner designated to provide the opinion, and the examination report must include a discussion of the Veteran’s documented medical history and assertions. The examiner should offer comments, an opinion, and a supporting rationale that address the following: (a.) Is it at least likely as not (a 50 percent probability or greater) that the Veteran’s right knee conditions was incurred in, aggravated by, or is otherwise etiologically related to the Veteran’s active duty service, to include due to her in-service duties as a medic? (b.) Is it at least likely as not (a 50 percent probability or greater) that the Veteran’s right knee condition was either caused or aggravated by her service-connected degenerative disc disease of the thoracic spine? In providing the requested opinion, the examiner must address the Veteran’s contentions regarding lifting people during her active duty service as a medic. See Apr. 2016 VA Form 9; Feb. 2017 Correspondence 2. Schedule the Veteran for an examination with an examiner other than the October and November 2020 examiners to fully assess the nature and severity of her service-connected allergic urticaria with anaphylaxis. Any indicated evaluations, studies or tests deemed necessary should be accomplished. The entire claims file, to include a complete copy of this REMAND, should be made available to the examiner designated to provide the opinion, and the examination report must include a discussion of the Veteran’s documented medical history and assertions. The examiner should offer an assessment of all pertinent symptomatology and findings, to be reported in detail in accordance with Diagnostic Code 7825. The examiner must also determine at what points during the appeal period (since August 2013) that the Veteran used immunosuppressive therapy, second line treatments, and third line treatments. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries and that her reports must be taken into account in formulating the requested opinions. The examiner must provide rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. Kate E. Kovarovic Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Watkins, 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.