Citation Nr: 21029828 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 16-03 396 DATE: May 17, 2021 REMANDED Entitlement to service connection for chronic fatigue syndrome, to include as secondary to service-connected disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1990 to July 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). A June 2019 Board decision, inter alia, remanded the claims of entitlement to service connection for (1) chronic fatigue syndrome, (2) irritable bowel syndrome, (3) a disability manifested by joint pain, to include polyarthralgia, (4) a disability manifested by muscle pain, to include polymyalgia, (5) fibromyalgia, and (6) gastroesophageal reflux disease (GERD) for additional development. In January 2021, the RO granted service connection for (1) GERD with Barrett's esophagus, gastritis, esophageal motility disorder, hiatal hernia, and irritable bowel syndrome, and (2) fibromyalgia with polyarthralgia (claimed as fibromyalgia, polyarthralgia, and polymyalgia). See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (noting that a grant of service connection extinguishes appeals before the Board). Unfortunately, there has not been substantial compliance with the Board's previous remand directive regarding chronic fatigue syndrome and another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). Although an examination was provided in November 2020, for the reasons provided below, it is inadequate. Where VA provides an examination or obtains an opinion, it must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Entitlement to service connection for chronic fatigue syndrome, to include as secondary to service-connected disability. The Veteran contends that his chronic fatigue syndrome is secondary to medications prescribed for his service-connected disabilities. See NOD (February 2013); Appellate Brief (May 2021). The Veteran's service-connected disabilities, relevant to the contentions, include post-traumatic stress disorder, degenerative arthritis of the lumbar spine, degenerative disc disease of the cervical spine, degenerative joint disease of the right ankle, residuals of bilateral knee surgery, residuals of right shoulder surgery, and radiculopathy. The June 2019 Board remand directed the RO to obtain an opinion on whether any identified chronic fatigue syndrome is due to or the result of the service-connected disabilities, to include the medications prescribed for those disabilities. Although a November 2020 VA medical opinion (VAMO) reflects that the Veteran's chronic fatigue syndrome is not secondary to his service-connected degenerative joint disease of the right ankle, there is no indication that the examiner considered the Veteran's numerous other service-connected disabilities. Additionally, the opinion does not reflect consideration of whether the Veteran's chronic fatigue syndrome is secondary to the medications prescribed for treatment of his service-connected disabilities, as specifically directed by the Board. See C&P Exam (November 2020). The November 2020 VAMO is also internally and externally inconsistent. Regarding internal inconsistency, the examiner provided a diagnosis date in November 2020, but noted in the medical history that the onset date was between 1995 and 1996. Id. Regarding external inconsistency, the November 2020 diagnosis date is at odds with a January 2011 VA examination, which provided a diagnosis of chronic fatigue syndrome. See VA Examination (January 2011). However, no explanation was provided to reconcile those inconsistencies. Notably, the January 2011 diagnosis of chronic fatigue syndrome was opined to be due to "a specific, identifiable etiology such as the daily use of zoloft, ambien, codeine and flexoril." Id. The January 2011 examiner did not specify that those medications were prescribed for service-connected disabilities. The November 2020 VAMO does not substantially comply with the Board's prior remand directives. 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. Therefore, to ensure that VA has met its duty to assist, remand is required. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician on the etiology of the Veteran's chronic fatigue syndrome. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. 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: (a.) Whether the Veteran's chronic fatigue syndrome at least as likely as not (1) began during active service or (2) is related to an in-service injury, event, or disease. (b.) Whether the Veteran's chronic fatigue syndrome is at least as likely as not (1) proximately due to service-connected disability(ies); or (2) aggravated beyond its natural progression by service-connected disability(ies), to include any medications prescribed for the treatment of his service-connected disability(ies). Provide a rationale that addresses causation and aggravation as independent concepts. 2. Ensure that the VA medical opinion obtained include 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, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. Readjudicate. 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.