Citation Nr: 21030864 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 18-10 292 DATE: May 19, 2021 REMANDED Entitlement to service connection for multiple sclerosis, to include all residuals and symptoms of multiple sclerosis, is remanded. Entitlement to service connection for diplopia, to include as due to multiple sclerosis, is remanded. REASONS FOR REMAND The Veteran had service with the Missouri Army National Guard, to include active duty service from September 1998 to November 1998. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a virtual hearing before the undersigned Veterans Law Judge in October 2020. A transcript of that hearing has been associated with the claims file. The Board finds that a remand is necessary in this case for further development. First, during her October 2020 hearing, the Veteran requested that VA obtain her Social Security Administration (SSA) records. While the RO has previously attempted to obtain SSA records and received a response that there were no medical records for the Veteran, the Board finds that an additional attempt should be made. In that regard, the Board notes that the RO previously requested medical records from the SSA. Upon remand, the agency of original jurisdiction (AOJ) should request the entire file, to include any decisions, assessments and/or medical records. Additionally, the Board notes that in October 2012, the Veteran submitted a statement documenting her prior marriages, as well as a statement that she served on active duty under a different surname. As such, the AOJ should contact the Veteran and obtain all of her legal name changes as well as the time period(s) of those changes, before requesting records from SSA, as perhaps a legal name change is the reason for SSA's inability to locate the records. The Board also finds that another VA medical opinion should be obtained for the Veteran's claims. In the September 2013 and August 2017 VA opinions, the VA examiners relied upon an October 1999 medical record indicating that the Veteran's multiple sclerosis symptoms began in 1994. However, the Board notes that medical records from that same provider, also dated October 1999, then indicate that multiple sclerosis symptoms began in service. The Veteran has further testified that the leg numbness she experienced in 1994 was related to her pregnancy and not her multiple sclerosis. As such, the Board finds that another VA medical opinion should be obtained, in order to consider all evidence and testimony. The examiner should note that the Veteran's current multiple sclerosis was not noted on the entrance examination. Further, in the event the condition is found to have pre-existed service, the correct standard to apply is whether the condition, which clearly and unmistakably existed prior to service, was clearly and unmistakable not aggravated beyond its natural progression by service. Such aggravation does not need to be permanent and/or irreversible. Accordingly, the case is REMANDED for the following action: 1. The agency of original jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for multiple sclerosis, residuals of multiple sclerosis, and diplopia. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. Any outstanding VA medical records should also be obtained and associated with the claims file. 2. The AOJ should also contact the Veteran and obtain any and all legal name changes she has had, as well as the time period(s) of those changes. 3. After obtaining the Veteran's legal name change(s) during the relevant time period, the AOJ should request a copy of any relevant SSA decisions to grant or deny disability benefits and the assessments and/or records upon which the decision(s) was based and associate them with the claims file. A list of the Veteran's relevant prior legal name(s) should be included in the request. If the search for such records has negative results, the claims file should be properly documented as to the unavailability of those records. 4. After completing directives #1-3, the AOJ should obtain a VA medical opinion regarding the Veteran's multiple sclerosis and any and all residuals, to include diplopia. Only if deemed necessary by the VA examiner is an actual examination necessary. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to matters of which she has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should note that the condition was not noted in the entrance examination; therefore, the presumption of soundness applies. The examiner should opine as to the following questions: 1) Does the evidence of record clearly and unmistakably show that the Veteran had multiple sclerosis prior to her entry onto active duty in September 1998? In responding to this question, the examiner is asked to consider all medical records in evidence and address the Veteran's testimony that her 1994 leg numbness was a symptom of her pregnancy and not multiple sclerosis. 2) If so, does the evidence of record clearly and unmistakably (undebatable) show that the multiple sclerosis and any residuals, was not aggravated by service or that any increase in disability was due to the natural progression of the disease? 3) If the answer to either (1) or (2) is no, is it at least as likely as not that the Veteran's multiple sclerosis and/or any residuals of multiple sclerosis, to include diplopia, is causally or etiologically related to her military service, to include symptomatology therein? (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 5. After completing these actions, the AOJ should conduct any other development as may be indicated by a response received as a consequence of the actions taken in the preceding paragraphs. Nathaniel Doan Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Rideout-Davidson, 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.