Citation Nr: 21025383 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 15-04 790 DATE: April 28, 2021 REMANDED Entitlement to service connection for back arthritis, low back strain, bilateral shoulder arthritis, bilateral knee arthritis, and bilateral hip strain, including as a medically unexplained chronic multisymptom illness (MUCMI), is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD), including as a MUCMI, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1990 to December 1991. He was deployed to Saudi Arabia during his active service. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a November 2012 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). A hearing was held before the undersigned in October 2017. In May 2018 and September 2020, the Board remanded the Veteran’s claims for additional development. A March 2021 rating decision allowed service connection for migraine headaches. This represents a full grant of the benefits sought on appeal as to this issue. The claim of entitlement to service connection for migraine headaches is no longer before the Board. See Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997). VA has a duty to ensure any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (overruled on other grounds, Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board’s evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). 1. Entitlement to service connection for back arthritis, low back strain, bilateral shoulder arthritis, bilateral knee arthritis, and bilateral hip strain, including as a medically unexplained chronic multisymptom illness (MUCMI),is remanded. 2. Entitlement to service connection for gastroesophageal reflux disease (GERD), including as a MUCMI, is remanded. In September 2010, the Veteran filed a claim seeking service connection for “Gulf War Syndrome headaches, fatigue, joint pian, acid reflux, memory problems.” Subsequently, service connection has been established for migraines headaches, chronic fatigue syndrome, and posttraumatic stress disorder with memory loss. An April 2019 VA examiner diagnosed GERD, bilateral shoulder arthritis, bilateral knee arthritis, back arthritis, low back strain, and bilateral hip strain. In July 2019, she opined these conditions were less likely than not directly related to the Veteran’s active service. In September 2020, the Board remanded the claim and requested a medical opinion to evaluate whether any diagnosed condition constituted a MUCMI, because either the etiology or the pathophysiology of a the condition was not at least partially understood. See Stewart v. Wilkie, 30 Vet. App. 383 (2018). In November 2020, additional VA esophageal conditions, back conditions, knee conditions, hip conditions, and shoulder conditions examinations were provided. Current diagnoses of GERD, bilateral knee arthritis, bilateral shoulder arthritis, degenerative disc disease, back arthritis, low back strain, and bilateral hip strain were confirmed. The examiner opined that the etiology of each condition was understood. He did not provide any opinion as to the pathophysiology of these diagnosed conditions. The opinion is inadequate to determine whether these conditions are MUCMI under the holding in Stewart. Id. In September 2020, the Board also noted the Veteran asserted in his October 2017 testimony, in a January 2015 statement, and in reports to the April 2019 examiner, that his digestive symptoms, back pain and/or joint pain were onset during his active service and his hip and knee pain began in 1992. For any condition which was not a MUCMI, the Board requested an opinion as to whether the condition was incurred in or caused by the Veteran’s active service. The examiner was advised that the Veteran was competent to report his experience of symptoms and their history. If these reports were dismissed, a complete rationale for doing so was required. The November 2020 examiner noted the Veteran’s reports as to the onset of his symptoms. He opined each disability (GERD, back, shoulder, knee, and hip) was at least as likely as not incurred during active service because he accepted the Veteran’s statements as “proof” that the conditions were incurred during active service. The examiner explained that he considered the Veteran’s statements to be “proof” of the etiology of each condition because the Board instructed that the Veteran was competent to report his symptoms and history. In January 2021, the examiner provided addendum opinions. He noted the service treatment records did not document any treatment for joint or digestive problems during the Veteran’s active service. However, in light of Veteran’s military occupational specialty (cannon crewmember) and his service history, he continued to accept the Veteran’s lay statements as “evidentiary proof in support” of his claims. The examiner concluded again that each diagnosed condition was at least as likely as not incurred during the Veteran’s active service. The Veteran, as a lay person, is competent to describe symptoms such as pain or digestive problems. He is not competent to diagnose a complex medical condition or to provide an etiology opinion for such a condition. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (except in limited circumstances, a layperson is not competent to provide evidence of diagnoses). Accordingly, the Veteran’s reports of symptoms are not “proof” that any complex medical condition was incurred during or is otherwise causally related to his active service. The examiner’s November 2020 and January 2021 positive etiology opinions for direct service connection are not based on a complete and accurate medical history. They are inadequate to evaluate the claims. See Stefl, supra. In February 2021, the examiner provided additional addendum opinions as to direct service connection. For bilateral hip strain, bilateral knee arthritis, back arthritis, bilateral shoulder arthritis, and GERD, the examiner noted the service treatment records were silent for any of these conditions and there were no clinical records documenting treatment for 20 years after the Veteran separated from active service. He then stated the hazards associated with the Veteran’s one year of active service, absent clinical records of any injury or symptoms, did not indicate a nexus between the conditions and active service. Contrary to his earlier opinions, he opined each condition was less likely than not incurred in or caused by service. In February 2021, the examiner dismissed the Veteran’s reports of symptoms because there were no contemporaneous medical records to support them. As the Veteran is competent to report his observable symptoms, this is not an adequate reason to dismiss the reports. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (that reports of symptomatology are not supported by contemporaneous clinical evidence does not render them inherently not credible). Accordingly, the February 2021 addendum opinions are also not based on a complete and accurate medical history and they are inadequate to evaluate the claims. See Stefl, supra. Currently, there are no adequate medical opinions addressing whether the Veteran’s back arthritis, low back strain, bilateral shoulder arthritis, bilateral knee arthritis, bilateral hip strain and GERD are MUCMI or are directly causally related to his active service. Additional etiology opinions must be obtained. The matters are REMANDED for the following action: Forward the entire claims file to an appropriate clinician who has not previously evaluated the Veteran’s claim. The clinician is asked to determine the nature and etiology of the Veteran’s GERD, bilateral shoulder arthritis, bilateral knee arthritis, back arthritis, low back strain, and bilateral hip strain. The examiner must review the entire claims file, including a copy of this remand. If the clinician determines an additional examination is required, schedule an examination. If feasible, schedule a telehealth examination. The clinician is asked to provide responses to the following (for each diagnosed condition): A) Is the etiology of the Veteran’s GERD, bilateral shoulder arthritis, bilateral knee arthritis, back arthritis, low back strain, or bilateral hip strain (1) inconclusive, (2) partially understood, or (3) fully understood? This determination must be based on the Veteran’s specific case and cannot be based on the etiology of the disease or disability in the population as a whole B) Is the pathophysiology of the Veteran’s GERD, bilateral shoulder arthritis, bilateral knee arthritis, back arthritis, low back strain, or bilateral hip strain (1) inconclusive, (2) partially understood, or (3) fully understood? This determination must be based on the Veteran’s specific case and cannot be based on the pathophysiology of the disease or disability in the population as a whole. If both the etiology and pathophysiology (for any diagnosed condition) are partially understood or fully understood, then is it at least as likely as not (a 50 percent or greater probability) that the condition (GERD, bilateral shoulder arthritis, bilateral knee arthritis, back arthritis, low back strain, or bilateral hip strain) was incurred in, or is otherwise related to, the Veteran’s active service? In providing this opinion, the clinician must discuss the Veteran’s reports to prior VA examiners, his January 2015 statement, and his October 2017 testimony. The clinician must discuss the Veteran’s assertions that his digestive symptoms, low back pain, and joint pain were onset during active service in Germany following his deployment to Southwest Asia or shortly after his separation from service. For arthritis, clinician should also opine whether the arthritis, in any joint where it is diagnosed, at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service (Continued on the next page)   The clinician is advised the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the clinician rejects the Veteran’s reports, he or she must provide a reason for doing so. The examiner may not dismiss the Veteran’s report of symptoms capable of lay observation solely because they are not documented in contemporaneous medical records. A complete rationale must be provided for all opinions expressed. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Jeanne Celtnieks 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.