Citation Nr: 21032283 Decision Date: 05/26/21 Archive Date: 05/26/21 DOCKET NO. 15-41 092A DATE: May 26, 2021 REMANDED The issue of service connection for sarcoidosis is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1982 to March 1985. This matter comes before the Board of Veterans' Appeals (Board) from a May 2013 rating decision from a Department of Veterans Affairs (VA) Regional office (RO). This matter was the subject of a Joint Motion for Partial Remand granted by the United States Court of Appeals for Veteran's Claims in July 2020. That order vacated a July 2019 Board decision and remanded the claim for additional development of medical records and to provide an adequate statement of reasons and basis for finding the Veteran's statement that he was diagnosed with sarcoidosis in 1985 or 1986 was not competent. A November 2020 Board remand directed the RO request the Veteran provide a release for private treatment records for medical treatment the Veteran identified in Philadelphia in February 1985, records from George Washington University Medical, and a "Dr. B. M." That same month the RO sent a letter to the Veteran requesting a release for the records from George Washington University Medical. The Veteran did not respond, and the claim was returned to the Board. A February 2021 Board remand directed the RO to comply with the prior remand orders to request that the Veteran provide a release for private treatment records from Philadelphia in 1985 and "Dr. B.M." The remand further requested the RO to obtain an opinion as to whether the Veteran's reports of chest pain in service were related to the current diagnosis of sarcoidosis. That same month the RO sent a letter to the Veteran requesting a release for the records from a facility in Philadelphia in 1985 and "Dr. B.M." In March 2021 the Veteran was provided an examination and an opinion was obtained as to the relationship between the Veteran's reported in-service chest pain and his current diagnosis of sarcoidosis. This matter is now before the Board once again. The Issue of Service Connection for Sarcoidosis Remanded. The matters are REMANDED for the following action: 1. BACKGROUND FOR THE ADJUDICATOR An opinion as to whether the Veteran's sarcoidosis was related to service was obtained in March 2021. This opinion was inadequate because the examiner's opinion is based on an inaccurate recitation of the record. It states the Veteran was not diagnosed with sarcoidosis until 2012. However, a treatment record from October 1994 notes the Veteran was first seen by "Dr. B.M." in 1993 for sarcoidosis. Additionally, a CT scan from August 2007 indicated sarcoidosis. Therefore, an addendum opinion which accurately recounts the record is required. Nevertheless, the Veteran has been requested to provide releases for relevant private medical records in November 2020 and February 2021. He failed to respond to both requests. THE VETERAN IS THEREFORE ADVISED THAT if a veteran fails to respond to a request for evidence within one year of the request, the claim will be considered abandoned and no further action will be taken on the claim. 38 C.F.R. § 3.158. THE VETERAN IS ALSO ADVISED THAT if he does not respond to the requests within one year, a new opinion will not be necessary as the Veteran's claim will be deemed abandoned. REMAND DIRECTIVES FOLLOW 2. Send the Veteran a copy of the original requests that the Veteran to authorize VA to obtain records from George Washington University Medical, a facility in Philadelphia, and "Dr. B.M." sent in November 2020 and February 2021. Notify the Veteran if he fails to respond to the original requests within one year, his claim will be considered abandoned under 38 C.F.R. § 3.158. 3. If and only if the Veteran responds to the above requests, return the claims file to the March 2021 VA examiner, and request he re-review the claims file and respond to the inquiry below. If the examiner is not available, arrange for another appropriately-qualified VA examiner to provide an addendum medical opinion to assist in determining the etiology of the Veteran's sarcoidosis. All appropriate tests, studies and consultations should be accomplished, including a new medical examination if necessary, and all clinical findings should be reported in detail in the narrative portion of the examination report. A rationale should be given for all opinions and conclusions rendered. Based upon a review of the relevant evidence of record, history provided by the Veteran, and sound medical principles, the VA examiner should provide the following opinion: (a.) Is the Veteran's sarcoidosis related to his active service, to include documented reports of chest pain in service between 1982 and 1985? (b.) Is the Veteran's reported diagnosis of sarcoidosis in 1985 or 1986 medically consistent with the subsequent development and documentation of the condition in the record? The examiner must review the entire record in conjunction with rendering the requested opinion. SPECIAL ATTENTION SHOULD BE PAID TO: *AN OCTOBER 1994 TREATMENT RECORD FROM "DR. B.M." NOTING SHE HAD FIRST SEEN THE VETERAN FOR SARCOIDOSIS A YEAR PRIOR AND THAT THE CONDITION WAS WELL CONTROLLED. *AN AUGUST 2007 CT SCAN INDICATING THE PRESENCE OF SARCOIDOSIS. A thorough explanation must be provided for the opinion rendered. If the examiner cannot provide the requested opinion without resorting to speculation, s/he should expressly indicate this and provide supporting rationale as to why the opinion cannot be made without resorting to speculation. 4. 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 S. Reed, Counsel The Board's action is binding only with respect to this matter decided. This remand is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.