Citation Nr: 21028246 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 16-04 153 DATE: May 10, 2021 REMANDED The issue of service connection for a vestibular disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Air Force from May 1954 to July 1963. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2014 rating decision of the Fort Harrison, Montana Regional Office (RO). In October 2018, the Veteran was afforded a hearing before the undersigned Veterans Law Judge (VLJ) sitting at the Houston, Texas RO. During the hearing, the VLJ engaged in a colloquy with the Veteran toward substantiation of the claim. Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). A hearing transcript is in the record. In February 2019, the Board denied the claim. The Veteran appealed the Board decision to the U.S. Court of Appeals for Veterans' Claims (Court). In a July 2019 Joint Motion for Partial Remand (JMPR), the Court vacated the Board decision and remanded the Veteran's appeal to the Board. In December 2019, the Board, pursuant to the Court's order, remanded the claim for a VA examination to determine whether the Veteran had a vestibular disorder and if so, whether it was caused by service. In June 2020, the Board denied the claim due in part to the January 2020 VA examiner's indication that the Veteran did not have vestibular disorder. The Veteran appealed the Board decision to the Court. In a December 2020 Joint Motion for Remand (JMR), the Court vacated the Board decision and remanded the Veteran's appeal to the Board. Vestibular disorder The matter is remanded for the following action: 1. BACKGROUND FOR THE RO ADJUDICATOR In December 2020, the Court found that the January 2020 VA examination was inadequate because the examiner, in finding that the Veteran did not have a diagnosed vestibular disorder, did not consider the April 2014 VA examiner's diagnosis of fainting and dizziness and the February 2018 VA treatment record's assessment of vertigo with post-tussive syncope occurring since the Veteran was 19 years old. The Board will remand for a VA addendum opinion. The Court also found that the Board did not consider the applicability of Clemons v. Shinseki, 23 Vet. App. 1 (2009) due to a July 2016 VA treatment record reflecting a diagnosis of "dizziness associated with a vascular disorder" and that the Veteran filed his claim of service connection for dizziness and fainting spells in July 2013. The Veteran's vascular disorder is not service connected. THE REMAND DIRECTIVES FOLLOW. 2.Return the file to the VA examiner who conducted the January 2020 VA examination for a file review and an addendum opinion. If the examiner is not available, have the file reviewed by a similarly qualified examiner. Another examination is not required; however, if the VA examiner indicates that he or she cannot respond to the Board's questions without examination of the Veteran, another examination should be afforded to the Veteran. All relevant medical and non-medical records must be available to the examiner for review of pertinent documents. The examination report should specifically state that such a review was conducted. The examiner must provide the following opinions: Does the Veteran have a diagnosis of a vestibular disorder? If the Veteran has a diagnosis of a vestibular disorder, was it caused by the Veteran's in-service reports of dizziness? THE EXAMINER IS ADVISED AS TO THE FOLLOWING: THE VETERAN IS PRESUMED SOUND AT SERVICE ENTRANCE AS TO HIS NEUROLOGICAL AND/OR VESTIBULAR FUNCTION. THE EXAMINER IS REQUIRED, BY COURT ORDER, TO CONSIDER THE VETERAN'S RELEVANT MEDICAL HISTORY AS OUTLINED BELOW, IN ADDITION TO THE APRIL 2014 VA EXAMINER'S DIAGNOSIS OF FAINTING AND DIZZINESS AND THE FEBRUARY 2018 VA TREATMENT RECORD'S ASSESSMENT OF VERTIGO WITH POST-TUSSIVE SYNCOPE. THE VETERAN IS COMPETENT TO REPORT HAVING EXPERIENCED DIZZINESS AND FAINTING SINCE SERVICE. Although the examiner must review the VBMS file, his or her attention is drawn to the following: A September 1954 service treatment record reflects the Veteran's report of experiencing dizziness, temporary weakness, and instability. In the Veteran's May 1957 service medical examination report, no neurological abnormalities were noted; however, the service medical examiner indicated that the Veteran had experienced dizziness and fainting spells. It was noted that the Veteran did not experience complications or sequelae. In the Veteran's May 1963 pre-separation medical examination, no neurological abnormalities were noted. A December 1998 VA treatment record reflects the Veteran's report of experiencing dizziness after having been prescribed Maxzide. In an October 1999 VA treatment record, the Veteran reported experiencing dizziness once every two weeks. He was diagnosed with dizziness. An April 2000 VA treatment record reflects the Veteran's report of experiencing dizziness after having been prescribed Terazosin. A June 2000 VA treatment record reflects the Veteran's report of experiencing dizziness. He was diagnosed with dizziness with orthostatic pulse change. An August 2000 VA treatment record reflects the Veteran's report of experiencing dizziness and having related dizziness from wearing his eyeglasses. In a July 2002 VA treatment record, the Veteran reported experiencing dizziness since 2000. He was diagnosed with dizziness. A February 2003 VA treatment record reflects the Veteran's report of experiencing dizziness, giddiness, blurred vision, and trouble with balance since 2002. In a July 2013 statement, the Veteran reported experiencing dizziness and fainting since June 1957. In the April 2014 VA central nervous examination, the Veteran reported experiencing dizziness. He was diagnosed with fainting and dizziness. A July 2016 VA treatment record reflects the Veteran's report of experiencing dizziness lasting several seconds that occurred every three months since 1954. The Veteran was diagnosed with dizziness and the VA treating physician noted that the Veteran's dizziness was consistent with a vascular disorder. In a February 2018 VA treatment record, the Veteran reported experiencing lightheadedness. The Veteran was diagnosed with vertigo with post-tussive syncope. The VA treating physician indicated that the Veteran did not have benign paroxysmal positional vertigo and noted that the Veteran's dizziness was possibly related to high blood pressure, changes in medication, or high blood sugar. In his October 2018 Board hearing, the Veteran testified to experiencing dizziness since September 1954. An April 2021 VA treatment record noted that the Veteran's dizziness "can be due to suboptimal titration of antihypertensive medication vs. syncope vs. posterior circulation dysfunction." In an April 2021 VA treatment record, a 20 year history of dizziness was noted. The Veteran reported experiencing dizziness as lightheadedness and no room spinning sensation. The Veteran also reported experiencing at least one syncopal episode, triggered with sudden changes in body position worsened when getting up and coughing. The VA staff neurologist noted that the Veteran's dizziness was "unclear etiology multifactorial" and that the "central cause unlikely given positional triggers." (Continued on the next page) 2. 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 B. Cohen, 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.