Citation Nr: 21032521 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 17-50 457 DATE: May 27, 2021 REMANDED Entitlement to service connection for essential tremors, including as a qualifying condition under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1982 to June 1992. In January 2020, in support of this claim, the Veteran testified at a hearing at the local regional office (RO) before the undersigned Veterans Law Judge of the Board (Travel Board hearing). A transcript of the proceeding is of record. In March 2020, the Board denied this claim, finding that the Veteran's symptoms were diagnosed and attributable to known medical conditions and, therefore, did not constitute a qualifying chronic disability under 38 C.F.R. § 3.317. As such, service connection was not warranted on the premise he has a medically unexplained chronic multi-symptom illness (MUCMI) of the type contemplated by this VA regulation or the governing statute, 38 U.S.C. § 1117. In addition, the March 2020 Board decision determined the Veteran's essential tremors were not caused by his service-connected PTSD. In response, the Veteran appealed the Board's decision to the higher U. S. Court of Appeals for Veterans Claims (Veterans Court/CAVC). In February 2021, the CAVC vacated the Board's March 2020 decision denying this claim pursuant to a Joint Motion for Partial Remand (JMPR), which agreed the Board had failed to provide an adequate statement of reasons or bases for its findings, specifically with regard to its discussion and application of 38 C.F.R. § 3.317. The JMPR states that, while the Board determined the Veteran "has not been shown to have a MUCMI," the October 2014 VA medical opinion was unable to trace the etiology and pathophysiology of his essentials tremors because his parents died earlier in a car accident. See Stewart v. Wilkie, 30 Vet. App. 383, 390 (2018). Although the June 2015 medical opinion explained that genetics are a general cause of essential tremors, the Board did not explain whether this indicates a conclusive etiology and pathophysiology of the Veteran's essential tremors. Therefore, an addendum medical opinion is needed to address the deficiencies prior to readjudicating this claim. In addition, the CAVC found that the June 2015 VA examination that the Board relied on in making its determination was inadequate because the examiner's opinion was limited to whether the Veteran's service-connected PTSD caused his essential tremors and failed to additionally comment on whether his service-connected PTSD alternatively aggravates his essential tremors. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013) (holding that medical opinions addressing the issue of secondary service connection are inadequate when they fail to adequately encompass the question of aggravation). Two opinions are required for secondary service connection claims: 1) is the claimed disorder "caused by" or "due to" the service-connected disability; and, 2) is the claimed disorder "aggravated by" the service-connected disability (Allen Aggravation). An opinion that something "is not related to" or "is not due to" does not answer the question of aggravation. Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310 (b). As a result, supplemental (addendum) medical comment is needed concerning this, as well. Accordingly, this claim is REMANDED for the following action: 1. Contact the Veteran and request authorization to obtain all outstanding records pertinent to this claim, whether VA and/or private, following proper procedures (38 C.F.R. § 3.159(c)). Notify him if unable to obtain records that have been sufficiently identified (38 C.F.R. § 3.159(e)). 2. After obtaining all additional treatment or other relevant records, obtain a supplemental (addendum) medical opinion from a qualified clinician concerning the nature, etiology, and pathophysiology of the Veteran's essential tremors. To this end, the relevant evidence in the claims file, including a complete copy of this remand and the JMPR, must be made available to the examiner. (a.) In relation to this claimed disability of essential tremors, the examiner must discuss both the etiology and pathophysiology of this disability with specific emphasis on whether both the etiology and pathophysiology of the condition is understood, or at least partially understood in the context of the Veteran's unique circumstances. The examiner should also comment on whether the cluster of the Veteran's symptoms as whole constitutes a MUCMI. (b.) The examiner should additionally opine on whether it is at least as likely as not (a 50 percent probability or greater) the Veteran's essential tremors are caused OR aggravated by his service-connected PTSD. If aggravation is found, please identify to the extent possible the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to aggravation of the Veteran's essential tremors by the service-connected PTSD. If it is necessary to have the Veteran re-examined to provide this additional comment, then have him re-examined. This is left to the examiner's discretion. Rationale for the opinions provided is essential. The mere absence of evidence of treatment for essential tremors in the Veteran's service treatment records (STRs) or even post-service treatment records cannot be the sole reason for providing an unfavorable opinion, certainly not in the context of secondary service connection. However, it is permissible to consider this as one of several factors - provided there also is explanation of why it is reasonable to expect documentation of specific complaints, etc., in the treatment records. The examiner is advised that the Veteran is competent to report his symptoms and history, and these reports must be acknowledged and considered in formulating responses. If the examiner rejects the Veteran's reports of symptomatology, a reason for doing so must be provided. KEITH W. ALLEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Mukherjee 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.