Citation Nr: 21027785 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 16-35 094 DATE: May 6, 2021 REMANDED Entitlement to an initial rating for a uterine disability, characterized as menorrhagia with fibroids, cervical dysplasia and polyps, status post uterine ablation; rated as 10 percent prior to July 8, 2020; rated as 100 percent from July 8, 2020 to October 8, 2020; and as 30 percent thereafter, is remanded. Entitlement to service connection for insomnia, including as secondary to a service-connected disability or disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1997 to September 1997, from January 2003 to April 2004, and from October 2011 to November 2012. This matter is before the Board of Veterans' Appeals (Board) on appeal of November 2014, March 2016 and January 2021 rating decisions of a Regional Office (RO) of the Department of Veterans Affairs (VA). In May 2018, the Board remanded these claims for additional development. A January 2021 rating decision allowed service connection for a bilateral foot disorder and for a back disorder. This represents a complete grant as to the benefit sought in those claims. The issues are no longer before the Board. See Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997). 1. Entitlement to an initial rating for a uterine disability, characterized as menorrhagia with fibroids, cervical dysplasia and polyps, status post uterine ablation; rated as 10 percent prior to July 8, 2020; rated as 100 percent from July 8, 2020 to October 8, 2020; and as 30 percent thereafter Under the duty to assist, VA must obtain VA authorized treatment records. See 38 C.F.R. § 3.159(c)(3); see also Sullivan v. McDonald, 815 F.3d 786, 793 (2016) (finding that the regulation extends the duty to assist to obtain "sufficiently identified VA medical records or records of examination or treatment at non-VA facilities authorized by VA, regardless of their relevance.") Further, VA must make reasonable efforts to assist the Veteran in obtaining relevant private medical records. 38 C.F.R. § 3.159(c)(1). The Veteran seeks an increased rating for a uterine disability. The record reflects that over the appeals period, she received gynecological treatment from private physicians and private medical facilities through VA referrals. VA treatment records include a September 2013 referral for this treatment from Dr. J. H. A June 2020 medical release form indicates the Veteran received treatment from Dr. J. H.through 2016. Records from this physician, after January 2014, are not included in the claims file. VA treatment records from April 2020 show a referral for gynecological care from Dr. C. B. Complete records from Dr. C. B. have not been obtained. Medical records associated with the claims file show the Veteran underwent a hysterectomy at the North Mississippi Medical Center (NMMC)--West Point in July 2020. It is not clear that complete records from NMMC-West Point have been obtained. The Board notes, VA treatment records refer to scanned documents from Dr. J. H.,Dr. C. B., NMMC (North Mississippi Medical Center)-West Point, and Baptist Medical Hospital. These scanned documents are not visible within the claim files. Accordingly, additional efforts must be made to obtain complete records for VA authorized private gynecological treatment and to make scanned records of this treatment visible within the claims file. 38 C.F.R. § 3.159(c). The Board also notes, the Veteran submitted forms authorizing the release of her medical records from Dr. J. H., Dr. C. B. and NMMC-West Point in June 2020 and July 2020. VA did not take any action following the submission of the forms to obtain the identified treatment records. If treatment was provided without VA referral, additional reasonable efforts must be made to obtain these additional outstanding private records. Id. 2. Entitlement to service connection for insomnia, including as secondary to a service-connected disability or disabilities, is remanded. 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). In December 2015, the Veteran filed a claim seeking service connection for insomnia. Military personnel records confirm her service in Afghanistan from November 2011 to September 2012. Following this deployment, August 2012, September 2012, and January 2013 post deployment health assessments show the Veteran reported problems sleeping. In May 2018, the Board remanded this claim to obtain a VA examination and etiology opinion. In part, the examiner was asked to determine whether insomnia was diagnosed. If this condition was diagnosed, the examiner was asked to provide an opinion as to whether it was causally related to her service, including environmental exposures during service in Southwest Asia during the Persian Gulf War. A VA mental disorders examination was provided in November 2019. The examiner diagnosed insomnia. She noted the Veteran had trouble falling asleep and staying asleep. Her symptoms began shortly after redeployment from Afghanistan. Service treatment records include her reports of difficulty sleeping in August 2012 and September 2012. While in Afghanistan, the Veteran reported experiencing repeated rocket attacks. She stated one of her roommates was killed in such an attack. The examiner opined that insomnia was not related to "experience in service." The condition was due to "stress in life but not due to service exposure." It appears the examiner may have limited her consideration of in-service experience to environmental exposures. In October 2020, the examiner provided an addendum opinion. She clarified that the Veteran's "insomnia is due to stress in [her] personal life" and the condition was "not service-connected." However, the examiner did not discuss the Veteran's reports of stressful events in Afghanistan, the stress of deployment, or personal life stress incurred during active service. Additionally, the examiner did not discuss the Veteran's report and the service treatment records documenting sleep problems immediately following her redeployment from Afghanistan. The November 2019 opinion and the October 2020 addendum opinion are inadequate to evaluate the claim. See Stefl, supra. The Board also notes, service connection is established for the Veteran's other disabilities, including dermatitis, pes planus, asthma, irritable bowel syndrome, menorrhagia, fibromyalgia, a back disorder, bilateral knee disorders, gastroesophageal reflux disorder, anemia, tinnitus, allergies, and female sexual arousal disorder. The Veteran's combined disability rating is 100 percent. Accordingly, the Veteran's multiple service-connected conditions impair her ability to function. These disabilities may result in stress which causes or aggravates her insomnia. An opinion addressing secondary service connection is required. See 38 C.F.R. § 3.310(a). The matters are REMANDED for the following action: 1. Obtain the Veteran's outstanding VA treatment records, including all outstanding records for private treatment provided through VA referral. Records from Dr. J. H., Dr. C. B., MNNC-West Point, and Baptist Medical Hospital, and any other treatment provider, who provided VA referred gynecological treatment, must be obtained. 2. Make additional efforts to ensure any private treatment records scanned into the VA treatment records are visible within claims file. 3. Ask the Veteran to complete a VA Form 21-4142 for any private treatment provider who may have records relevant to her claim, if a current VA Form 21-4142 is not within the file. Make two requests for the authorized records from any private treatment provider unless it is clear after the first request that a second request would be futile. 4. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's insomnia is at least as likely as not related to her active service, including reports of stressful events, including deployments, during active service. The examiner should specifically discuss the Veteran's reports and the service treatment records indicating sleep problems began shortly after her redeployment from Afghanistan. (Continued on the next page) The examiner should also opine whether insomnia is at least as likely as not proximately due to any service connected condition (dermatitis, pes planus, asthma, irritable bowel syndrome, menorrhagia, fibromyalgia, a back disorder, bilateral knee disorders, gastroesophageal reflux disorder, anemia, tinnitus, allergies, and female sexual arousal disorder), including stress related to a service connected condition, or aggravated beyond its natural progression by a service-connected disability, including stress related to a service connected disability. Aggravation and causation are distinct are distinct theories and must be addressed separately and independently of each other. 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.