Citation Nr: 21022435 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 14-35 374 DATE: April 15, 2021 REMANDED Entitlement to service connection for a sinus headache condition, to include as a qualifying chronic disability or undiagnosed illness is remanded. Entitlement to service connection for a thoracolumbar spine disability, to include as secondary to a service-connected right ankle disability is remanded. Entitlement to left hip disability, to include as secondary to a service-connected right ankle disability is remanded. Entitlement to service connection for a right hip disability, to include as secondary to a service-connected right ankle disability is remanded. Entitlement to service connection for a left knee disability, to include as secondary to a service-connected right ankle disability is remanded. Entitlement to service connection for a right knee disability to include as secondary to a left knee disability or a service-connected right ankle disability is remanded. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from March 1987 until March 1993. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In February 2018, the Veteran testified before the undersigned Veterans Law Judge during a Board video conference hearing. These matters were previously before the Board in May 2018 and November 2020 but were remanded to further develop his records and obtain adequate VA examinations. In a recent January 2021 supplemental statement of the case (SSOC), his service connection claims were denied. These matters are again before the Board for adjudication. REASONS FOR REMAND 1. Service connection for a sinus headache disability, to include as a qualifying chronic disability or undiagnosed illness is remanded. Upon review of the evidence, the Board finds that additional remand is necessary prior to adjudication of the claim. First, during the February 2018 Board hearing, the Veteran testified that he was treated by a private provider for his sinus headaches in Florida. However, it does not appear that efforts have been made to contact the Veteran for information necessary to obtain these private treatment records identified by him. Second, in the November 2020 Board remand, the VA examiner was requested to provide a medical opinion on etiology of the Veteran’s sinus headache disability. The Veteran was provided with a VA examination in January 2021. However, the Board finds that the January 2021 VA medical opinion is incomplete and inadequate. The Board observes that the VA examiner noted the Veteran’s various sinus disabilities and that he also experienced headaches related to his sinus conditions. However, the VA medical opinion focuses only on the Veteran’s sinus disabilities but does not specifically address his sinus headache disability that is on appeal. As such, the Board finds that the January 2021 VA examination is inadequate and incomplete as it fails to properly address the right disability on appeal. Once VA undertakes to provide a medical examination, VA must provide an adequate examination or, at a minimum, notify the claimant why one will not or cannot be provided. 38 C.F.R. § 4.2; Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). Based on the foregoing reasons, the Board concludes that a remand is warranted to obtain additional private treatment records and a new VA examination. 2. Service connection for a thoracolumbar spine disability, to include as secondary to a service-connected right ankle disability is remanded. 3. Service connection for a right hip disability, to include as secondary to a service-connected right ankle disability is remanded. 4. Service connection for a left knee disability, to include as secondary to a service-connected right ankle disability is remanded. 5. Service connection for a right knee disability to include as secondary to a left knee disability or a service-connected right ankle disability is remanded. The Board further finds that additional remand is necessary before the Board can adjudicate the merits of the Veteran’s service connection claim for his thoracolumbar spine, bilateral hip, and bilateral knee disabilities. As an initial matter, the Board remanded the Veteran’s thoracolumbar spine, bilateral hip, and bilateral knee disabilities claims in May 2018 to obtain a medical opinion addressing whether these disabilities were secondary to his service-connected right ankle disability. The Veteran was provided with a VA examination in October 2019. However, in a November 2020 remand, the Board found that the October 2019 VA examiner failed to provide clear conclusions with supporting data in support of the medical opinion for secondary service connection. The Board further noted that the examiner failed to provide a reasoned medical explanation in support of the opinion. Additionally, the Board noted that the VA examiner’s findings that he had no current bilateral hip and bilateral knee disability conflicted with the Veteran’s medical treatment records. As such, his service connection claims for a thoracolumbar spine, bilateral hip, and bilateral knee disabilities were remanded to obtain an adequate VA medical opinion and to reconcile the conflicting diagnosis. Specifically, the VA examiner was requested to opine on whether it was at least as likely as not that these disabilities were (1) proximately caused or a result of the service-connected right ankle disability or (2) aggravated beyond its natural progression due to the Veteran’s service-connected right ankle disability. The Board observes that the Veteran was provided with another VA examination in January 2021. However, the Board finds that the January 2021 VA medical opinions for the Veteran’s thoracolumbar spine, bilateral hip, and bilateral knee disability are incomplete. While the VA examiner rendered a medical opinion addressing the second prong of service connection, the aggravation prong, the VA examiner failed to address the first prong, proximate causation. Accordingly, the Board finds that the January 2021 VA opinion is incomplete and did not substantially comply with the November 2020 remand instructions. Accordingly, another remand is required to obtain a supplemental VA opinion. See Stegall v. West, 11 Vet. App. 268 (1998); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Allen v. Brown, 7 Vet. App. 439, 448 (1995). The matters are REMANDED for the following action: 1. Contact the Veteran for the necessary information to obtain private treatment records for treatment of his sinus headaches when he resided in Florida. Also, obtain any outstanding VA treatment records for his sinus headaches, thoracolumbar spine, bilateral hip, and bilateral knee disability that are not currently of record. 2. After, schedule the Veteran for a VA examination for his sinus headaches, thoracolumbar spine, bilateral hip, and bilateral knee disability to determine the etiology of the Veteran’s disabilities. Provide the claims file, including a copy of this remand, to the examiner for review. The examiner is requested to provide a medical opinion for the following questions: (a) Regarding his sinus headaches disability, is it at least as likely as not (50 percent or greater) that his sinus headaches disability is etiologically related to an in-service event, injury, or disease? (b) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s sinus headache is an undiagnosed illness or a medically unexplained chronic multi-symptom illness (MUCMI) under 38 C.F.R. § 3.317? In providing a medical opinion, the examiner is requested to consider and address the Veteran’s lay statements , to include the February 2018 Board hearing, that his symptoms began after returning from the Persian Gulf. (c) Regarding his thoracolumbar spine, bilateral hip, or bilateral knee disability, is it at least as likely as not (50 percent probability or greater) that the disability is proximately caused by or a result of his service-connected right ankle disability? (d) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s thoracolumbar spine, bilateral hip, or bilateral knee disability was aggravated beyond its natural progression by his service-connected right ankle disability? (e) If and only if service connection is established for the Veteran’s left knee disability, then the examiner is requested to opine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s right knee disability was (1) proximately caused by or a result of the left knee disability or (2) aggravated beyond its natural progression by the left knee disability. In rendering an opinion, the examiner is requested to consider and address the Veteran’s lay statements regarding the onset of his thoracolumbar spine, bilateral hip, and bilateral knee disability. A complete and detailed rationale for these opinions should be provided for every opinion requested by the examiner. The examiner should fully articulate a sound reasoning for all conclusions made. 3. After, readjudicate the claim. If the benefit sought on appeal remains denied, furnish the Veteran with a supplemental statement of the case (SSOC) and provide him with an appropriate opportunity to respond. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Xiong, 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.