Citation Nr: 21025791 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 16-39 689 DATE: April 29, 2021 REMANDED Entitlement to service connection for sarcoidosis is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1988 to October 1988 and from September 1990 to April 1991, with service in Southwest Asia during the Persian Gulf War. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an August 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The appeal was previously remanded by the Board in October 2018 and July 2020. Unfortunately, there has not been substantial compliance with the Board's previous remand directives regarding the issue on appeal. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for sarcoidosis is remanded. Although the Board regrets the additional delay, the Board finds that further development is required before the claim on appeal can be decided. Unfortunately, as noted above, there has not been substantial compliance with the Board's previous remand directives regarding the issue of entitlement to service connection for sarcoidosis. The Veteran contends that his current sarcoidosis is related to his military service. Specifically, the Veteran attributes his shortness of breath and chest congestion to medication received in service, to include an anthrax vaccine. See July 2011 private treatment record and May 2012 Statement. The Veteran has also asserted that his respiratory problems could be related to in-service exposures during his period of service in Southwest Asia during the Gulf War, to include exposure to dust storms, burn pits burning feces, and diesel fumes. See July 2013 VA Gulf War and Respiratory Disorder examination reports. As aforementioned, the Board remanded the claim in July 2020 for an addendum opinion regarding the etiology of the Veteran’s diagnosed sarcoidosis that addresses the Veteran’s lay statements and all theories of entitlement. In an October 2020 addendum medical report, the VA examiner rendered a negative nexus opinion on all theories of entitlement. Regarding whether the sarcoidosis is causally related to the Gulf War environmental exposures, the examiner stated that “sarcoidosis is attributed to both environment and genetics. The veteran is in a high-risk demographic group that is susceptible to sarcoidosis. It is unknown what exposures or combinations of exposures can trigger sarcoidosis in susceptible individuals. It is also unknown what post military occupational exposures had been encountered prior to the abnormal chest x-ray in 1994.” The examiner continues noting that “further research is indicated before a nexus between sarcoidosis and GW exposures can be established.” The examiner did not indicate what research was indicated and whether this was further testing or questioning of the Veteran which could be undertaken or whether the research depended upon the knowledge within the medical community. See Sharp v. Shulkin, 29 Vet. App. 26 (2017) (quoting Jones v. Shinseki, 23 Vet. App. 382, 390 (2010)) (Before the Board can accept an examiner’s statement that an opinion cannot be provided without resort to speculation, it must be clear that this is predicated on a lack of knowledge among the medical community at large and not the insufficient knowledge of the specific examiner). The Board finds this opinion is inconclusive and therefore is not adequate for adjudicating purposes. The Board cannot make a fully informed decision on the issue of the Veteran's sarcoidosis because no VA examiner has sufficiently opined regarding the nature and etiology of the Veteran's asserted condition. Thus, a remand for an addendum opinion is necessary. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician. The clinician must be provided with and review the entire claims file, to include a copy of this remand. Following a review of the evidence of record, to include the Veteran's lay statements, the clinician should opine: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's sarcoidosis had its onset during active duty or is causally or etiologically related to any in-service event, disease, or injury. In so opining, the clinician is asked to reconcile, to the extent possible, the Veteran's noted report of having shortness of breath and coughs for 20 years in VA treatment records from July 2011. (b.) Whether it is at least as likely as not (50 percent probability or higher) that the Veteran's sarcoidosis was manifested within one year of his separation from active service? The examiner must address the Veteran’s assertions that the Anthrax vaccine and/or the Atropine pills received in service are the cause of his respiratory disorder, including whether or not such medication causes respiratory problems, and his assertion that his respiratory symptoms could be due to exposures during his Persian Gulf War service (such as dust storms, burn pits, burning feces, and diesel fumes). The examiner is advised that the term "as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. If the examiner cannot provide the requested opinion without resorting to speculation or a lack of knowledge within the medical community, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. If further testing needs to be conducted, the examiner should attempt to obtain such testing. The examiner must provide the underlying reasons for any opinions provided. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Romero-Sanchez, 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.