Citation Nr: 21025090 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 17-38 220 DATE: April 27, 2021 REMANDED Entitlement to service connection for right paralyzed hemidiaphragm with exercise induced bronchospasm, to include as due to exposure to environmental hazards and/or secondary to service-connected gastroesophageal reflux disease (GERD) is remanded. REASONS FOR REMAND The Veteran served in the Army from July 1988 to September 1992. This matter comes before the Board of Veteran’s Appeals (Board) on appeal from a December 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In June 2018, March 2019, March 2020, and July 2020, the Board remanded this claim for additional development. The Veteran was previously represented by a private attorney; however, the attorney withdrew representation in a letter dated November 2019. The Veteran has not appointed a new attorney, agent, or representative. 1. Entitlement to service connection for right paralyzed hemidiaphragm with exercise induced bronchospasm, to include as due to exposure to environmental hazards. is remanded. Regrettably, a remand for a new medical opinion is necessary, specifically, an expert medical opinion from Veterans Health Administration (VHA). Furthermore, additional VA treatment records were added to the claims file following the issuance of the September 2020 SSOC. The Board notes that this claim has been remanded multiple times during the appeal. In the most recent Board remand, the RO was directed to obtain an addendum opinion. In providing the requested medical opinion, the examiner was asked to consider and discuss the following: 1) the Veteran’s lay statements concerning his in-service symptoms of dyspnea and coughing; 2) the Veteran’s exposure to burn pits during service; 3)the Veteran’s lay statements concerning his post-service symptoms of dyspnea and coughing, to include during the police academy; 4) the April 2019 VA treatment note that diagnosed the Veteran with paralyzed right hemidiaphragm and opined it was likely caused by viral infection; and, 5) the Veteran’s asserted theory that the November 1988 documented in-service complaint of difficulty breathing with a diagnosis of tonsillitis was the viral infection that caused his paralyzed right hemidiaphragm. The Veteran was afforded a VA opinion in September 2020.The examiner stated that he reviewed the July 2020 remand letter. The examiner reported that upon review of available medical records, it is acknowledged that the Veteran is identified to have paralyzed right hemidiaphragm which was supported by a diaphragm fluoroscopy. The examiner reported that the medically acknowledged causes for phrenic nerve (the nerve that is responsible for the diaphragms movement) paralysis are stroke, diaphragmatic trauma or surgery or neuromuscular disorders. The examiner noted that the Veteran has denied suffering from any of those conditions. The examiner reported that on February 11, 2019, the Veteran was seen by a pulmonary specialist who noted that the Veteran displayed with pulmonary restriction after spirometry which was consistent with the paralysis of the hemidiaphragm. The VA examiner noted that the February 2019 pulmonary specialist further stated that there was “no significant breathing problems” and that the “cough appears secondary to acid reflux.” The examiner expressed that the physician requested several diagnostic exams, and concluded that it is likely that the cause of the paralysis is a viral illness. The examiner stated that current medical literature identifies three infectious causes for phrenic nerve paralysis, West Nile virus, dengue virus, and Lyme disease. The examiner expressed that these complications, however, are extremely rare with only two documented cases of phrenic nerve paralysis due to West Nile virus. The examiner noted that the Veteran suffered a viral tonsillitis while in service, however, West Nile virus and dengue fever are not the cause of viral tonsillitis. The examiner noted that exposure to burn pits are acknowledged to cause coughing and dyspnea because these are pulmonary irritants but does not subsequently lead an individual to acquire asthma. Thus, the examiner opined that it is less likely than not that the Veteran has right paralyzed hemidiaphragm with exercise induced bronchospasm had its onset during service or is causally or etiologically due to service, to include exposure to environmental hazards, such as burn pits, or the documented viral infection of tonsillitis during service. In a September 2020 Correspondence letter, the Veteran noted that the examiner reported that the Veteran’s cough was from acid reflux but chose to leave out his bronchial spasm and the effects of having one lung and its difficulty in breathing. In an October 2020 Correspondence letter, the Veteran stated that he was deployed to Panama where there is still an abundance of mosquitoes and malaria. In addition, the Veteran indicated the he jumped from airplanes thirty times, and thus his hard landings could have been considered blunt trauma. As far as burn pits are concerned, the Veteran stated that the September 2020 VA examiner acknowledged that burn pits are irritants that cause coughing, however, the examiner did not explain why his asthma did not go away since service. After review, the Board finds that a new opinion is required from an expert from VHA. First, the Board finds that the September 2020 VA examiner did not address the Veteran’s lay statements concerning his in-service symptoms of dyspnea and coughing that have been continuous since service. Second, the September 2020 VA examiner noted that the Veteran denied suffering from any condition that is medically acknowledged to cause phrenic nerve paralysis to include diaphragmatic trauma. However, the Veteran reported that he experienced blunt trauma after jumping from airplanes. Third, the September 2020 VA examiner reported that current medical literature identifies three infectious causes for phrenic nerve paralysis, West Nile virus, dengue virus, and Lyme disease. The examiner expressed that these complications are extremely rare. However, the Board notes that an April 2019 VA treatment note indicated that the Veteran’s paralyzed right hemidiaphragm was likely caused by viral infection. Thus, the Board finds that an opinion is necessary in order to reconcile the difference in opinions. In addition, the Veteran indicated that he was deployed to Panama where there is an abundance of mosquitoes and malaria. Finally, an opinion that discusses secondary service connection. The September 2020 VA examiner noted that the February 2019 pulmonary specialist stated that the Veteran’s cough appears secondary to acid reflux. In addition, the April 2020 VA examiner noted that the Veteran’s asthma was not aggravated by exercise but from his gastroesophageal reflux disease (GERD). The Veteran is currently service connected for GERD, and thus the Veteran’s right paralyzed hemidiaphragm with exercise induced bronchospasm may be aggravated by the Veteran’s GERD and an opinion is necessary. The matters are REMANDED for the following action: 1. Obtain a medical opinion from a Veterans Health Administration (VHA) physician with the appropriate expertise to address the nature and etiology of the Veteran’s right paralyzed hemidiaphragm with exercise induced bronchospasm. The claims file, including a copy of this Remand, must be made available and reviewed by the examiner. The examiner is requested to review all pertinent records associated with the claims file and offer comments and an opinions addressing whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran’s right paralyzed hemidiaphragm with exercise induced bronchospasm had an onset during service, or is causally or etiologically due to service, to include exposure to environmental hazards, such as burn pits, or the documented viral infection of tonsillitis during service. In providing the requested medical opinion, the examiner must consider and discuss the following: 1) the Veteran’s lay statements concerning his in-service symptoms of dyspnea and coughing; 2) the Veteran’s exposure to burn pits during service; 3) the Veteran’s lay statements that he experienced diaphragmatic trauma after jumping from airplanes. 4) Veteran’s lay statements concerning his post-service symptoms of dyspnea and coughing, to include during the police academy; 5) the April 2019 VA treatment note that diagnosed the Veteran with paralyzed right hemidiaphragm and opined it was likely caused by viral infection; and, 6) the Veteran’s asserted theory that the November 1988 documented in-service complaint of difficulty breathing with a diagnosis of tonsillitis was the viral infection that caused his paralyzed right hemidiaphragm and/or his exposure to mosquitoes that transmitted malaria. The examiner should ALSO address whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran’s right paralyzed hemidiaphragm with exercise induced bronchospasm was proximately caused or aggravated by his service-connected GERD. The examiner should note that this question requires two separate opinions: one for proximate causation and a second for aggravation. The examiner is asked to review the lay statements as they relate to the development of his diagnosed disorder and provide information as to how the statements comport with generally accepted medical norms. 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. If the examiner rejects the Veteran’s reports of symptomatology, then a reason for doing so must be provided.  The examiner is also advised that the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. In providing all the above opinions, the examiner is requested to review all pertinent records associated with the claims file. A clear rationale for all opinions is requested and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.D. 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.