Citation Nr: 21032567 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 17-67 956 DATE: May 27, 2021 REMANDED Entitlement to service connection for a disability manifested by dizziness, to include as secondary to tinnitus, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from May 1982 to April 1986. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In October 2019, the Veteran testified before the undersigned Veterans Law Judge. In March 2020, the Board remanded the matter for additional development. The Veteran asserts that he has vertigo and suffers from dizziness that is related to an in-service football head injury or in the alternative is secondary to his service-connected tinnitus. The Veteran's service treatment records were associated with the claims file on January 19, 2017, years prior to the Board's remand, wherein it specifically found that the RO should attempt to obtain the Veteran's complete service treatment records, to include his separation Report of Medical History. The RO did not attempt to obtain any service treatment records responsive to the Board's March 2020 remand directive. On remand, the RO should attempt to obtain his complete service treatment records, specifically, service treatment records beyond what were already available and associated with the claims file on January 19, 2017. Furthermore, the Veteran has reported on multiple instances that he experiences intermittent dizziness and loss of balance. The Veteran is competent to report this symptom. Although this symptom may not be related to a specific diagnosis such as Meniere's disease or vertigo, it may nonetheless be considered a disability if it results in a functional impairment. Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018). During his September 2020 VA examination, the Veteran reported his disability manifested by dizziness impacts his ability to work. Specifically, the Veteran reported that he must avoid high areas and high altitude due to his episodic vertigo. As such, this matter must be remanded to obtain an adequate opinion as to whether the Veteran's functional impairment, manifested by dizziness, is related to his service or secondary to his service-connected tinnitus. Finally, outstanding VA and private treatment records should be secured on remand. The matters are REMANDED for the following action: 1. Obtain a complete copy of the Veteran's service treatment records, to include his separation Report of Medical History at service separation. If any records are unavailable, notify the Veteran pursuant to 38C.F.R. §3.159(e). 2. With any necessary assistance from the Veteran, obtain all outstanding private treatment records, to include December 2016 Ear, Nose, and Throat records from Sutter Health. If any records are unavailable, notify the Veteran pursuant to 38C.F.R. §3.159(e). 3. Then obtain an addendum opinion regarding the etiology of the Veteran's current disability manifested by dizziness. No additional examination of the Veteran is necessary unless the reviewing examiner deems otherwise. After a review of the claims file, the examiner is requested to provide a specific opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's conceded functional impairment, manifested by dizziness: a) is related to service, to include his reported 1985 football head injury. See October 2019 Hearing at 7-8. b) manifested within one year after separation from service (in the case of any currently diagnosed organic disease of the nervous system). c) is (1) proximately due or (2) aggravated (worsened beyond natural progression) to his service-connected tinnitus. In addressing secondary service connection, please note that tinnitus need not be diagnosed or service-connected at the time the disability manifested by dizziness is incurred to establish secondary service connection, and reliance on this fact will render any secondary opinion inadequate. Additionally, please do not rely on the absence of a "current disability" in rendering your opinion, as the Board has conceded the presence of a current disability based on functional impairment associated with dizziness. If you rely on a lack of a diagnosed disability in your opinion, it will be returned as inadequate. The clinician is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinions. A complete rationale must be provided for all opinions. If unable to opine without resorting to speculation, please provide a basis for reaching this conclusion. S. BUSH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Forde, 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.