Citation Nr: 21028263 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 16-26 573 DATE: May 10, 2021 REMANDED Entitlement to service connection for a gynecological condition, to include metrorrhagia or menorrhagia, is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1984 to July 1986. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2014 rating decision. In November 2018 and July 2020, the Board remanded these issues for further development, and the case has been returned for appellate consideration. The Veteran sought service connection for "severe menstrual bleeding," however, medical records indicate that she has had a history of both irregular menstrual bleeding as well as severe bleeding. See Claim, received 4/8/2015; December 2014 C&P Exam; October 2020 C&P Exam; CAPRI, received 8/25/2020; STR, received 2/13/2014. Therefore, the Board has recharacterized her claim as one for service connection for a gynecological condition, to include metrorrhagia or menorrhagia. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (stating that when a claim is made, the Veteran is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled). 1. Gynecological Condition The Veteran seeks service connection for a gynecological condition, contending that she had onset of severe menstrual bleeding during service. See Claim, received 4/8/2015. Another remand is required to obtain outstanding relevant medical records and to thereafter obtain a new medical opinion as to the etiology of the Veteran's gynecological condition. Medical records show that the Veteran underwent a hysterectomy at Barnes Jewish Hospital in June 2020. CAPRI, received 8/25/2020. Those medical records, however, have not been associated with the claims file. Therefore, on remand, attempts should be made to obtain those medical records. 38 C.F.R. § 3.159(c); see also Bell v. Derwinski, 2 Vet. App. 611 (1992). Thereafter, a VA examination is required to determine the nature and etiology of the Veteran's gynecological condition, taking into account the record evidence and accepted medical principles. 38 C.F.R. § 3.159(c)(4). 2. TDIU In its November 2018 remand, the Board found that the issue of entitlement to TDIU was raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Social Security Administration (SSA) denied the Veteran's claim for disability benefits. See SSA Profile & Benefit Data, received 11/14/2019. A copy of a May 2018 SSA decision that was obtained outside channels with SSA suggests that the SSA may possess relevant evidence concerning the nature and severity of the Veteran's service-connected disabilities and whether they render her unable to secure or follow a substantially gainful occupation. See SSA/SSI Letter, received 4/28/2021. Attempts to obtain the relevant underlying records in that adjudication have not been made. Therefore, on remand, attempts should be made to obtain relevant records from SSA pertaining to the Veteran's employability. 38 C.F.R. § 3.159(c). These matters are REMANDED for the following actions: 1. Obtain any outstanding VA and/or private treatment records relevant to treatment the Veteran received for her gynecological condition that are not already of record, particularly the records for a hysterectomy in June 2020 at Barnes Jewish Hospital. All obtained records should be associated with the evidentiary record. If any identified records are not obtainable (or none exist), the Veteran should be notified, and the record clearly documented. 2. Contact SSA and request a copy of any SSA decision on entitlement to disability benefits to the Veteran, copies of all treatment (medical and mental) records upon which any such SSA disability benefits determination was based, and a copy of any medical records associated with any subsequent disability determinations by SSA. A copy of any response(s) from SSA, to include a negative reply, should be included in the claims file. All records provided by SSA also should be included in the claims file, to include uploading any disc supplied by SSA to the Veteran's electronic record. 3. Thereafter, schedule the Veteran for an examination by an appropriately qualified clinician to address nature and etiology of her gynecological condition, to include metrorrhagia or menorrhagia. All studies, tests, and evaluations deemed necessary by the examiner should be performed. The claims file should be made available to the examiner, and the examiner should review the claims file in forming the requested opinion. The examiner is asked to identify all gynecological conditions found to be present since the date of claim, June 6, 2012, and to opine whether it is at least as likely as not that the Veteran's gynecological condition, to include metrorrhagia or menorrhagia, had its onset during active duty service or is otherwise related to service. The examiner must obtain a full history from the Veteran. In rendering this opinion, the examiner is advised that the Veteran is competent to report her symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. The examiner should provide a detailed rationale that fully explains all the reasons for the given opinion. A discussion of the facts and medical principles involved would be of considerable assistance to the Board. The examiner must address any conflicting medical evidence of record. If an opinion cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. (Continued on the next page) 4. Readjudication the claims. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Leanne M. Innet, 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.