Citation Nr: 21025533 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 11-05 649A DATE: April 28, 2021 REMANDED Entitlement to service connection for chest pain, to include costochondritis, is remanded. REASONS FOR REMAND The Veteran was a member of the United States Marine Corps Reserve, with a period of active duty for training from November 1984 to July 1985, and a period of active duty from December 1990 to May 1991, to include service in Southwest Asia. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2007 rating decision by the Regional Office (RO) of the United States Department of Veterans Affairs (VA) in Decatur, Georgia, which denied to reopen the claim for entitlement to service connection for chest pain with shortness of breath. Most recently, in an October 2020 decision, the Board remanded this issue for additional development. Unfortunately, the requested development was not substantially completed and a remand for additional development is warranted. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for chest pain, to include costochondritis, is remanded. The Veteran is seeking service connection for chest pain. Specifically, he contends that his chest pain is related to his service in Saudi Arabia. See May 1992 VA Form 9. By way of history, the Veteran was initially denied service connection for chest pain in February 1992, on the basis that, although musculoskeletal chest pain complaints were noted in service, the Veteran’s service treatment records (STRs) and most recent VA examination did not show any diagnosis for a chronic disease that caused chest pain with shortness of breath. The Veteran was again denied service connection in July 1998 for chest pains with shortness of breath due to an undiagnosed illness on the basis that there was no objective medical or nonmedical evidence indicating that the Veteran suffered from a disability due to chest pain. The Veteran did not appeal this decision, rendering it final. In January 2005, the Veteran was again denied service connection for chest pain with shortness of breath as due to an undiagnosed illness on the basis that it did not qualify as a chronic disability. It was further noted that the evidence submitted since the prior July 1998 rating decision was not new and material. However, in July 2005, within a year of this denial, the Veteran provided private treatment records from December 2004 which indicate that he received treatment for complaints of chest pain. Since new and material evidence was received prior to the expiration of the appeal period, this January 2005 rating decision was not final. 38C.F.R. §3.156(b). In a May 2016 Board remand, the Board recharacterized the claim for service connection for costochondritis. Boggs v. Peake, 520 F.3d 1330, 1335-36 (Fed. Cir. 2008). The Board further recognized that an appeal of the October 2007 rating decision was perfected by a March 2010 Form 9 and remained on appeal. The Board directed that the Veteran be provided adequate notice regarding the requirements necessary for reopening the claim, which was provided in August 2016 and May 2017. In an April 2019 decision, the Board remanded the claim for additional VA records to be reviewed. Most recently, in an October 2020 decision, the Board found that since the most recent final denial in July 1998, updated VA treatment records and private records which raise the possibility that the Veteran has a current chest pain disability had been associated with the claims file. The Board accordingly found that new and material evidence had been received and the Veteran’s service connection claim for chest pain to include costochondritis was reopened. See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). The Board then noted that the most recent VA examination was in December 1996 and remanded the issue for additional development. Pursuant to the remand directives, in January 2021, the Veteran was afforded a VA examination. In the report, the examiner asserted that the Veteran does not have a current diagnosis of a muscle injury. The examiner also noted the Veteran’s symptoms of “chest pain with exertion” which is treated with medication. The examiner then opined that the Veteran’s condition was less likely than not related to service because there is no current pathology of a chest condition upon which to render a medical opinion. Unfortunately, the Board finds that this VA examination and opinion are insufficient for adjudicative purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Specifically, the examination report is vague with regard to describing any functional loss produced by the Veteran’s chest pain. The examiner only indicates that the Veteran experiences chest pain with “exertion” and does indicate the nature or severity of the Veteran’s chest pain. Because this information is not of record, the claim must be returned to the AOJ so that an additional examination may be performed and a measurement of functional loss/impairment resulting from the Veteran’s chest pain may be obtained. Relatedly, the examiner did not provide a medical opinion regarding the etiology of chest pain condition because the examiner did not find a diagnosed condition. For the purposes of VA compensation, however, pain alone may be considered a disability, even in the absence of an underlying diagnosis, when such pain contributes to functional loss. Saunders v. Shulkin, 886 F.3d 1356 (Fed. Cir. 2018). Here, the Veteran has complained of consistent pain since service. An adequate examination must address whether such pain contributes to functional loss, irrespective of whether it can be attributed to an underlying diagnosis, while also addressing whether such pain is causally related to service. Furthermore, the Board also notes that the Veteran served in Southwest Asia. Although the Veteran was afforded Gulf war guidelines examination in October 2005, it does not appear that the Veteran’s chest pains were reviewed as part of the examination and the January 2021 VA opinion does not address whether the Veteran’s chest pains are a chronic medically unexplained chronic multi symptom illness. See October 2005 Gulf War Guidelines Examination. Based on the foregoing, a remand for additional development and new VA examination and opinion is warranted. The matters are REMANDED for the following action: 1. Obtain all relevant outstanding VA treatment records, and any private treatment records identified by the Veteran. All records and/or responses received should be associated with the claims file. 2. After all outstanding treatment records have been associated with the claims file, schedule the Veteran for an appropriate VA examination to determine the nature, severity, and etiology of his chest pain. The record, to include a copy of this Remand, must be made available to and be reviewed by the examiner, and the examination report should note that review. The VA examiner/clinician should address the following: a) Identify all chest disabilities. Any needed diagnostic testing should be performed. (i) If no disability is identified, the examiner MUST discuss any abnormal findings noted and provide a detailed discussion of whether these findings and/or symptoms cause functional loss. See Saunders v. Shulkin, 886 F.3d 1356 (Fed. Cir. 2018) (Undiagnosed conditions may be service connected if such conditions cause functional impairment.) (ii) If no disability is identified, the examiner MUST also discuss whether the Veteran’s chest pain is a chronic medically unexplained chronic multi symptom illness (MUCMI) related to Gulf War Illness. (b) The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) the Veteran’s chest pain had its clinical onset during active service or is related to service, to include as due to: (i) his service in Southwest Asia, (ii) inservice chest pains, and (iii) inservice treatment for “PPD.” In doing so please specifically address the Veteran’s chronic complaints of and treatment for chest pain in service, to include the complaints noted on separation. Please also address the Veteran’s contentions that pain continued after service. The examiner should also consider the February 1991 STR showing chest pain with tightening and shortness of breath, May 1991 STR showing the Veteran was medically evacuated from Saudi Arabia due to chest pain, June 1991 STR noting chest pain 3-4 times a week, October 1991 VA examination, November 1991 statement in support of claim, May 1992 VA Form 9, December 1996 VA examination noting that during service the Veteran had a “PPD positive” and was treated during service and also had shortness of breath (see also January 2005 VA Treatment Records), October 2005 VA examination noting an inservice diagnosis of costochondritis after presenting with shortness of breath and chest pain. The examination report must include a complete rationale for all opinions provided. If the examiner cannot provide the requested opinion(s) without resorting to speculation, the report should expressly indicate this, and the examiner should explain why an opinion cannot be provided without resorting to speculation. (Continued on the next page)   3. After undertaking any additional development deemed necessary, the AOJ must readjudicate the claim on appeal. If the claim remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and afforded the requisite opportunity to respond before the case is returned to the Board. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Kaufer, 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.