Citation Nr: 21028069 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 14-42 063 DATE: May 10, 2021 REMANDED Entitlement to service connection for rheumatoid arthritis is remanded. Entitlement to service connection for fibromyalgia is remanded. Entitlement to service connection for Raynaud's disease is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1981 to August 1986 and from February 1990 to November 1994. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2012 rating decision by a Regional Office (RO) of the United States Department of Veterans Affairs. In a September 2018 decision, the Board reopened the previously denied claims and remanded them for additional development. Board decisions in February 2020 and September 2020 remanded the claims again for further development. The Board finds that there has not been substantial compliance with the Board's previous remand directives and another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). Although examinations were provided and opinions obtained in October 2020, for the reasons provided below, they are inadequate. Where VA provides an examination or obtains an opinion, it must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). 1. Entitlement to service connection for rheumatoid arthritis. 2. Entitlement to service connection for fibromyalgia. 3. Entitlement to service connection for Raynaud's disease. Issues 1 3: The Veteran contends that she was exposed to environmental contaminants from servicing vehicles returning from the Persian Gulf War, see Statement In Support of Claim (January 2008), and that her service treatment records (STRs) show "elevated erythrocyte sedimentation rate (ESR, or sed rate) or C-reactive protein (CRP)" indicating an inflammatory disease. See Correspondence (April 2020). The Veteran further contends that her claimed autoimmune diseases are secondary to her service-connected idiopathic thrombocytopenia. Id. The Board's September 2020 remand directed the RO to obtain medical opinions on whether the claimed disabilities of rheumatoid arthritis and fibromyalgia are secondary to service-connected idiopathic thrombocytopenia, and whether the claimed disability of Raynaud's disease is secondary to any other service-connected disability. However, the October 2020 examination reports and accompanying opinions provide no indication that a secondary theory of service connection was considered. Notably, the examiner provided no explanation regarding why an opinion regarding secondary service connection was not provided. A remand by the Board imposes upon the Secretary of VA a concomitant duty to ensure compliance with the terms of the remand. Where remand orders of the Board are not complied with, the Board errs in failing to ensure compliance. Stegall, 11 Vet. App. at 271. Additionally, the October 2020 VA medical opinions are inadequate as they indicate that the examiner's rationale relied on the absence of a diagnosis for the claimed disabilities during the Veteran's service as the basis for the negative opinion. The examiner opined, inter alia, that the claimed disabilities are not related to the Veteran's service as there is "no documentation in the Veteran's available medical records that the Veteran was diagnosed [with the claimed disabilities] by a medical professional while she was on active duty." See C&P Exam (November 2020). However, an in-service diagnosis is not required to establish service connection. Cosman v. Principi, 3 Vet. App. 503 (1992); see also 38 C.F.R. § 3.303(d) (service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service). Further, the examination reports indicate that fibromyalgia and Raynaud's disease were diagnosed in 1997 per the Veteran. However, as a lay person, the Veteran is not competent to provide a medical diagnosis or to determine the etiology of her claimed disabilities. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Although lay statements regarding the onset of symptoms are relevant to determining the proper diagnosis and onset date, the Veteran is not competent to provide a medical diagnosis or assign an onset date for such diagnosis. Overall, the medical examination reports and opinions are inadequate to sufficiently inform the Board of a medical expert's judgment on a medical question, whether there is a current disability and the etiology for such, and the essential rationale for that opinion." Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). Therefore, to ensure that VA has met its duty to assist, remand is required. 38 C.F.R. § 3.159(c)(4); Barr, supra. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from October 2020 to the Present. 2. Obtain a VA medical opinion from an appropriate clinician to address the nature and etiology of (1) rheumatoid arthritis, (2) fibromyalgia, and (3) Raynaud's disease. The clinician must indicate when each disease was first documented. The opinion should, among other things, include a discussion of the Veteran's documented history and assertions. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): An adequate medical opinion may not be predicated solely on the absence of medical studies or literature supporting causation or aggravation. The clinician must opine on: Direct Service Connection (a) Whether (1) rheumatoid arthritis, (2) fibromyalgia, and (3) Raynaud's disease at least as likely as not (1) began during active service or (2) are related to an in-service injury, event, or disease, to include exposure to environmental contaminants from servicing vehicles returning from the Persian Gulf War. Secondary Service Connection (b) Whether (1) rheumatoid arthritis, (2) fibromyalgia, and/or (3) Raynaud's disease are at least as likely as not (1) proximately due to service-connected disability, to include idiopathic thrombocytopenia; or (2) aggravated beyond its natural progression by service-connected disability, to include idiopathic thrombocytopenia. Provide a rationale that addresses causation and aggravation as independent concepts. 3. Ensure that the VA medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Thaddaeus J. Cox, 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.