Citation Nr: 21031347 Decision Date: 05/21/21 Archive Date: 05/21/21 DOCKET NO. 14-25 487A DATE: May 21, 2021 REMANDED Entitlement to service connection for insomnia, as due to an undiagnosed illness and/or as secondary to service-connected disabilities is remanded. Entitlement to service connection for reflex sympathetic dystrophy (RSD), to include as secondary to fibromyalgia, is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1986 to June 1991. He testified at a videoconference hearing before the undersigned in January 2019. A transcript of the hearing is of record. These claims were previously before the Board in May 2020, at which time they were remanded for further development. They have now been returned for further appellate review. The Board observes that the Veteran has requested another Board hearing pertaining to a separate claim for a higher migraine headaches rating. As that hearing has not yet taken place, such will be discussed in a future decision. 1. Entitlement to service connection for insomnia, as due to an undiagnosed illness and/or as secondary to service-connected disabilities is remanded. As discussed in the May 2020 Board decision, the Veteran's attorney has asserted that the Veteran's insomnia is a diagnosable but medically unexplained chronic multisystem illness of unknown etiology that warrants service connection as Gulf War Syndrome. However, the Veteran's representative also noted that insomnia has been identified as a symptom of the Veteran's service-connected PTSD. See id; see also January 2019 Hearing Transcript. Due to conflicting VA examination opinions of record, on remand, the Board directed the agency of original jurisdiction (AOJ) to schedule the Veteran for another VA examination in order to assess the nature and etiology of his insomnia disability. The Veteran underwent VA examination in January 2021. Upon examination, the VA examiner noted that insomnia was not a separately diagnosed disability but rather a current symptom of the Veteran's diagnosed mood disorder and posttraumatic stress disorder (PTSD.) However, the examiner also opined that it was at least as likely not that the Veteran's insomnia symptoms were a manifestation of a chronic multi-symptom illness with a partially explained etiology. Due to the contradictory nature of the January 2021 VA examiner's opinions regarding the etiology of the Veteran's insomnia, remand is warranted so that an addendum opinion can be obtained. 2. Entitlement to service connection for RSD, to include as secondary to fibromyalgia, is remanded. The Veteran's attorney has asserted that the Veteran's longstanding RSD diagnosis is either due to Gulf War service, or is secondary to his service-connected fibromyalgia. In its May 2020 decision, the Board directed the AOJ to schedule the Veteran for an examination to assess the etiology of his RSD. Specifically, the examiner was directed to opine as to whether it was at least as likely as not that the Veteran's RSD had onset in, or was otherwise related to his active service, including his service in Southwest Asia, as well as whether the Veteran's RSD was caused or aggravated by his service-connected fibromyalgia. The Veteran underwent VA examination in June 2020. Upon examination, the VA examiner opined that it was less likely than not that the Veteran's RSD had onset in or was otherwise related to service. However, the VA examiner's opinion is conclusory in nature as after a short recitation of the Veteran's Southwest Asia exposure and timeline of symptomology, the examiner merely stated that "there is no link between his active duty and his history of [RSD]" without out providing any rationale as to why the stated timeline supported such a conclusion. Further, while the examiner, opined that there was no causative relationship between the Veteran's fibromyalgia and his RSD, when addressing aggravation, the examiner simply stated that there was no objective evidence of RSD on exam and that a baseline of severity could not be determined. Based on the foregoing, the Board finds that remand is warranted so that an addendum opinion can be obtained regarding the etiology of the Veteran's RSD. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from a qualified professional assessing the nature and etiology of the Veteran's insomnia. It is left to the discretion of the examiner as to whether an in-person examination is necessary. The Veteran's claims file must be made available to, and reviewed by the examiner. Upon review of the record, the examiner should respond to each of the following: (a.) Clarify the Veteran's disability. Specifically, identify whether the Veteran has a stand-alone diagnosis of insomnia, or whether insomnia is a symptom of another disability. Please explain the medical reasons in support of the conclusion. (b.) If the Veteran's has stand-alone diagnosis of insomnia, please answer the following: i. indicate whether it is at least as likely as not (50 percent or greater probability) that such disability had onset in, or is otherwise related to the Veteran's period of service, to include exposure to environmental hazards while serving in Southwest Asia. ii. indicate whether it is at least as likely as not that such disability was caused or aggravated by service-connected disabilities, to include PTSD, migraine headaches, chronic fatigue and/or fibromyalgia. (c.) If the Veteran's insomnia symptoms are not manifestations of a stand-alone insomnia disability, but rather a symptom of a different disability, this should be made clear. In particular, the examiner should indicate whether it is at least as likely as not that (50 percent or greater probability) that insomnia is a manifestation of an undiagnosed illness, a chronic multisymptom disability of unknown etiology, or a chronic multi-symptom illness with a partially explained etiology. All opinions should be supported with a medical explanation or rationale. 2. Obtain an addendum opinion from a qualified professional assessing the nature and etiology of the of the Veteran's reflex sympathetic dystrophy (RSD). It is left to the discretion of the examiner as to whether an in-person examination is necessary. The Veteran's electronic claims file must be made available to, and reviewed by the examiner. Upon review of the record, the examiner should respond to each of the following: (a.) Is it at least as likely as not that the Veteran's RSD had onset in, or is otherwise related to his active duty service, to include his service in Southwest Asia? If the Veteran's RSD is a manifestation of an undiagnosed illness, a chronic multisymptom disability of unknown etiology, or a chronic multi-symptom illness with a partially explained etiology this should be made clear, with an explanation as to how the conclusion was reached. (b.) Is it at least as likely as not that the Veteran's RSD has been caused or aggravated by his service-connected fibromyalgia, to include medications taken for fibromyalgia? All opinions should be supported with a medical explanation or rationale. (Continued on Next Page) 3. Then, readjudicate the issues on appeal. If the benefits sought remain denied, in whole or in part, send the Veteran and his attorney a supplemental statement of the case. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Bristow Williams, 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.