Citation Nr: 21042429 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 17-39 139 DATE: July 13, 2021 REMANDED Entitlement to service connection for an autoimmune disease, to include rheumatoid arthritis and systemic lupus erythematosus, is remanded. REASONS FOR REMAND The Veteran had active duty service from January 1963 to July 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO), which continued the previous denial of service connection for chronic rheumatoid arthritis. In an April 2019 rating decision, the Board reopened and remanded the issue of service connection for an autoimmune disease for additional evidentiary development. Entitlement to service connection for an autoimmune disease, to include rheumatoid arthritis and systemic lupus erythematosus, is remanded. The Veteran's service-treatment records reveal complaints of severe pain in his feet in December 1965. He was assessed with suspect rheumatoid versus gout. It was noted that he probably had Reiter's syndrome. During his July 1966 separation examination, it was noted that he had painful feet. A September 2014 treatment record noted a past medical history of rheumatoid arthritis. The Veteran submitted a January 2015 foot disability questionnaire by L.M., M.D. Dr. L.M. assessed the Veteran with rheumatoid arthritis. She indicated that a rheumatoid panel was performed. Dr. L.M. concluded that it was as likely as not that his right foot rheumatoid arthritis was caused by his service. She reasoned that his post-service occupations were primarily sedentary. His primary military duty was an air policeman, requiring him to stand in one place for as much as 12 hours per day. The in-service climate changes were extreme and ranged from tropical to artic. Such conditions, along with ill-fitting footwear, would create a situation where the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as to find against it. A March 2016 medical opinion found that it was at least as likely as not that chronic foot pain from an autoimmune disease first noted in service caused an altered weight bearing and contributed to the onset of hallux valgus. The Veteran's treating healthcare provider evaluated him for rheumatoid arthritis in March 2017. His symptoms of pain, tenderness to touch, and swelling were present for several years. He reported onset of symptoms during his time in the military and noted that his symptoms have waxed and waned over the years. He was assessed with rheumatoid arthritis. In a subsequent March 2017 record, his treating healthcare provider noted his correct diagnosis was systemic lupus erythematosus (SLE) instead of rheumatoid arthritis. Pursuant to the Board's remand instructions, a medical opinion was obtained by a rheumatologist in May 2021. The examiner concluded that his current diagnosis of SLE has no relation to any disability that was incurred while serving active duty. The examiner reasoned that he was not diagnosed with rheumatoid arthritis or SLE while on active duty and there was no evidence to support the statement in the March 2016 medical opinion, which noted that the Veteran had an autoimmune disease first noted in service. After a review of the evidence, the Board finds that the May 2021 medical opinion is insufficient to determine the present claim. In this regard, the examiner failed to acknowledge or discuss the service-treatment records noting suspect rheumatoid. Moreover, the examiner failed to discuss or acknowledge the September 2014 medical record noting a past medical history of rheumatoid arthritis and the January 2015 medical questionnaire by Dr. L.M. assessing the Veteran with rheumatoid arthritis, noting a rheumatoid panel, and concluding that it was related to service. Lastly, the examiner failed to acknowledge or discuss the March 2017 medical record noting that his symptoms of pain, tenderness, and swelling began during his time in the military and have waxed and waned over the years. Accordingly, the Board finds that an addendum opinion is warranted on remand. The matter is REMANDED for the following actions: 1. Obtain and associate with the claims file the Veteran's updated VA treatment records from April 2021 to the present. 2. After completion of #1, forward the claims file, including a copy of this remand, to the May 2021 examiner for an addendum opinion. If the examiner is not available, forward to an additional rheumatologist. An examination is only necessary if deemed so by the examiner. The examiner should review the claims file in its entirety and respond to the following: A. Does the Veteran have a current diagnosis of rheumatoid arthritis throughout the rating period on appeal, or from February 2016? The examiner should discuss his treatment records noting a past medical history of rheumatoid arthritis and the January 2015 foot disability questionnaire by Dr. L.M. B. For any diagnosed autoimmune disease, including rheumatoid arthritis and/or systemic lupus erythematosus, is it at least as likely as not (probability of at least 50 percent) that it had its onset in and/or is otherwise etiologically related to service? The examiner must provide a comprehensive rationale for each opinion provided. The examiner should discuss the Veteran's service-treatment records, January 2015 foot disability questionnaire by Dr. L.M., March 2016 VA medical opinion, and March 2017 private treatment records. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. (Continued on the next page) If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Merrick 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.