Citation Nr: 21025619 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 16-15 156A DATE: April 28, 2021 REMANDED The issue of service connection for a vestibular disorder identified with symptoms of dizziness, headaches, double vision, and unsteadiness is remanded. REASONS FOR REMAND The Veteran had active duty for training (ACDUTRA) from November 1969 to March 1970. The Veteran also served in the Army Reserves until June 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). Service Connection for a Disorder Identified with Symptoms of Dizziness, Headaches, Double Vision, and Unsteadiness is remanded. The matters are REMANDED for the following action: 1. BACKGROUND FOR RO ADJUDICATOR In February 2020 the United States Court of Appeals for Veterans Claims (Court) remanded the appeal to the Board. The Court ordered that VA broadly interpret the Veteran’s claim to include any disorder or disorders that include the Veteran’s claimed symptoms of dizziness, headaches, double vision, and unsteadiness. The Board remanded the matter in October 2020 to consider any vestibular disorder. The Veteran underwent a VA examination in January 2021. However, disorders beyond the narrow consideration of a vestibular disorder were not considered even though the record suggested other causes for the symptoms. October 2014 treatment records suggest the Veteran’s symptoms may be related to alcohol abuse, which was granted service connection with depression in August 2019. The same records suggest the symptoms may also be related to residuals of an anoxic brain injury that was incurred after an accidental overdose resulted in respiratory failure in June 2014. The January 2021 examiner does not appear to have considered the multitude of documented reports of symptoms such as dizziness, blurred vision, unsteadiness, and syncopal episodes when concluding the Veteran did not have a vestibular disorder. Instead the examiner’s report solely focused on the denial of vertigo at the January 2021 and September 2015 examinations when determining there is no current vestibular disorder. The Remand Directives Follow 2. Advise the Veteran that he may submit any additional medical and non-medical evidence relating to his claimed disability that is not already in VA’s possession. 3. Associate with claims file, all records in VA’s possession relating to the treatment of Veteran’s claimed disability. 4. After any outstanding evidence is associated with the claims file, return the claims file to the January 2021 examiner, and request that she re-review the claims file and respond to the inquiry below. If the examiner is not available, arrange for another appropriate examiner to provide an addendum opinion on the nature and etiology of the Veteran’s claimed disorder. All appropriate tests, studies and consultations should be accomplished, including a new medical examination if necessary, and all clinical findings should be reported in detail in the narrative portion of the examination report. A full explanation should be given for all opinions and conclusions rendered. Based upon a review of the relevant evidence of record, history provided by the Veteran, and sound medical principles, the VA examiner should provide the following opinion: (a.) Identify any disorder or disorders, for which the Veteran may be properly diagnosed that encompass his symptoms of dizziness, headaches, double vision, and unsteadiness. The examiner should specifically consider vestibular disorders and residuals of anoxic brain damage. (b.) For each identified disorder state whether it was caused by the Veteran’s service, to include an in-service fall and shooting of machine guns and cannons. (c.) For each identified disorder state whether it was caused by any of the Veteran’s service-connected disabilities (tinnitus, hearing loss, and depression and depression with alcohol use disorder). (d.) For each identified disorder state whether it was aggravated, made worse, by any of the Veteran’s service-connected disabilities (tinnitus, hearing loss, and depression with alcohol use disorder). IN ADDITION TO ANY RECORDS ADDED TO THE FILE AS A RESULT OF THE ABOVE-DIRECTED DEVELOPMENT, the examiner’s attention is drawn to the following: *An April 1999 treatment record documenting complaints of dizziness. *A December 2005 report that the Veteran has fallen due to dizziness. *An April 2006 report of unsteadiness. *June 2014 records relating to treatment for an accidental opioid overdose. *A June 2014 report of unsteadiness. *October 2014 records relating to an emergency department visit for dizziness, vision change, and confusion. *An August 2015 record where the Veteran requested a referral for symptom of headaches and double vision. *June 2019 records related to repeated syncopal episodes. 5. Readjudicate the issue on appeal. If the benefit sought on appeal remains denied, the Veteran should be provided a supplemental statement of the case (SSOC). An appropriate period should be allowed for response before the case is returned to the Board. Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Reed, 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.