Citation Nr: 22012235 Decision Date: 03/03/22 Archive Date: 03/03/22 DOCKET NO. 18-22 948A DATE: March 3, 2022 REMANDED Entitlement to service connection for left shoulder strain is remanded. Entitlement to service connection for fibromyalgia, to include as secondary to service-connected post-traumatic stress disorder (PTSD) is remanded. Entitlement to service connection for sleep apnea (OSA), to include as secondary to service-connected PTSD is remanded. Entitlement to service connection for peptic ulcer disease (PUD), to include as secondary to service-connected anemia, and to include as secondary to service-connected PTSD, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 1979 to November 1980 and from June 1983 to December 1984. In August 2021, the Veteran testified before the undersigned Veterans Law Judge (VLJ) in a Virtual Hearing. A transcript of that proceeding has been prepared and associated with the file. Of note, the issue of service connection for a respiratory condition, to include sinusitis and asthma, is on appeal from the Court of Appeals for Veterans Claims. However, as the Court held in Clark v. O'Rourke, 30 Vet. App. 92 (2018), the Board must wait 90 days after sending notice of a court remand unless the Veteran knowingly and intentionally waives his or her right to the 90-day period. As there is no waiver in the file, and it has not been 90 days since notice was sent to the Veteran, the Board will not address this issue herein. 1. Entitlement to service connection for left shoulder strain is remanded. The Veteran testified that her left shoulder was injured when she was a truck driver in the Army and when she was injured using a power floor buffer in the barracks, as well as a fall escaping from a gas station explosion. In the April 2016 VA examination, the examiner diagnosed the Veteran with left shoulder strain. The examiner noted her report of injury from a gas pump explosion. The entire medical opinion was provided as follows: "Is [left] shoulder DJD [degenerative joint disease, arthritis] as least as likely as not due to PTSD? No, no evidence of this at all." No direct service connection opinion was provided. Moreover, in the same examination, the examiner reported that the Veteran did not have DJD, and yet provided an opinion not for the diagnosed left shoulder strain, but only for DJD. It is unclear to the Board if the Veteran has arthritis, a chronic disease, in the left shoulder. For an opinion to be adequate, it must include consideration of the Veteran's statements, be based on accurate factual premises, and contain a rationale sufficient to support its conclusions. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005) (a VA examination must be based on an accurate factual premise); see also Nieves-Rodriguez v. Peake, Vet. App. 295 (2008) (explaining that a medical report without "a reasoned medical explanation" lacks probative value). Here, no rationale was offered, nor were the Veteran's statements considered. For all these reasons, a remand is necessary to obtain an examination and medical opinion sufficient for adjudication purposes. 2. Entitlement to service connection for fibromyalgia, to include as secondary to service-connected post-traumatic stress disorder (PTSD) is remanded. The Veteran testified that she was exposed to traumatic events in-service and that fibromyalgia is due to her service-connected PTSD. In addition, she submitted an article showing a connection between fibromyalgia and her service-connected PTSD and a Mayo Clinic article on fibromyalgia. In the April 2016 VA examination, the Veteran was diagnosed with fibromyalgia. The same examiner for her shoulder claim provided a similar medical opinion, "Is fibromyalgia at least as likely as not due to PTSD? No, no medical evidence of being linked to that." No rationale was provided. As stated above, a medical report without "a reasoned medical explanation" lacks probative value. Nieves-Rodriguez v. Peake, Vet. App. 295 (2008). Accordingly, a remand is necessary as the Board requires a medical opinion that addresses the new evidence in the form of medical articles and provides a sufficient rationale for adjudication purposes. 3. Entitlement to service connection for sleep apnea (OSA), to include as secondary to service-connected PTSD is remanded. The Veteran testified that she had no problems sleeping prior to active-duty service. She stated that she believed her OSA was the result of the depression from her service-connected PTSD. She also stated that due to her depression, she "gained all kinds of weight," raising the issue of obesity as intermediate step between her service-connected PTSD and her diagnosed OSA. Walsh v Wilkie, 32 Vet. App. 300 (2020). In April 2016, the Veteran attended a VA Sleep Apnea examination. The examiner reported a diagnosis of obstructive sleep apnea and noted a September 2006 sleep study, as well as use of continuous positive airway pressure (CPAP) machine. The same examiner for her shoulder and fibromyalgia claims concluded that her OSA is not at least as likely as not due to PTSD and stated, "No. There is no med literature linking sleep apnea with PTSD." No other rational was given. The Veteran has submitted medical literature from the American Academy of Sleep Medicine showing that the probability of having high risk of OSA increased with the increasing severity of PTSD symptoms. As shown above, a medical report without "a reasoned medical explanation" lacks probative value. Nieves-Rodriguez v. Peake, Vet. App. 295 (2008). Accordingly, a remand is necessary as the Board requires a medical opinion that addresses the medical article and provides a sufficient rationale for adjudication purposes. 4. Entitlement to service connection for peptic ulcer disease, to include as secondary to service-connected anemia, and to include as secondary to service-connected PTSD is remanded. The Veteran testified that her stomach problems began in basic training and she was diagnosed with gastritis. She stated that she was subsequently diagnosed with an ulcer and she has had ulcer problems continuously since her time in service. In April 2016, the Veteran attended a VA Esophageal Conditions examination. Peptic ulcer disease (PUD) was diagnosed. The examiner noted that the Veteran had a long history of anemia and it was "unknown if related to GI system." The examiner did not opine on her service-connected anemia and PUD and concluded that her PUD was not due to her PTSD ("No, no med evidence linking PTSD to...PUD."). As noted above, for an opinion to be adequate, it must contain a rationale sufficient to support its conclusions. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005) (a VA examination must be based on an accurate factual premise); see also Nieves-Rodriguez v. Peake, Vet. App. 295 (2008) (explaining that a medical report without "a reasoned medical explanation" lacks probative value). Here, only a conclusory statement was provided regarding the Veteran's PUD and service-connected PTSD; no opinion was provided regarding her PUD and service-connected anemia. Thus, a remand is necessary as the Board requires a medical opinion regarding the Veteran's claimed PUD and her service-connected PTSD and anemia. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records since April 2020 and associate them with the file. 2. Schedule the Veteran for a VA examination for her left shoulder condition. The examiner must review the claims file. All necessary diagnostic tests and/or diagnostic imaging should be conducted, and the examiner should review those results prior to providing an opinion. The examiner is asked to provide a response to the following: Is the Veteran's left shoulder condition at least as likely as not related to service, including her injuries in service when using a power floor buffer in the barracks, as well as a fall escaping from a gas station explosion. If the Veteran's left shoulder condition is diagnosed as arthritis, a chronic disease, is it at least as likely as not that the left shoulder arthritis (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? 3. Schedule the Veteran for a VA examination for her fibromyalgia. The examiner must review the claims file. All necessary diagnostic tests and/or diagnostic imaging should be conducted, and the examiner should review those results prior to providing an opinion. The examiner must address the medical literature submitted from the Mayo Clinic and WebMD in August 2021. The examiner is asked to provide a response to the following: Is the Veteran's fibromyalgia at least as likely as not related to service, to include her testimony of painful aches while on active duty? Is the fibromyalgia at least as likely as not proximately due to service-connected PTSD? Is the fibromyalgia at least as likely as not aggravated, i.e., worsened beyond its natural progression, by her service-connected PTSD? 4. Schedule the Veteran for a VA examination for her obstructive sleep apnea (OSA). The examiner must review the claims file. All necessary diagnostic tests and/or diagnostic imaging should be conducted, and the examiner should review those results prior to providing an opinion. The examiner must address the medical literature from the American Academy of Sleep Medicine submitted in August 2021. The examiner is asked to provide a response to the following: Is the Veteran's OSA at least as likely as not proximately due to service-connected PTSD? Is the Veteran's OSA at least as likely as not aggravated, i.e., worsened beyond its natural progression, by her service-connected PTSD? Did the Veteran's service-connected disability PTSD, to include prescribed medications to treat her PTSD symptoms, cause the veteran to become obese or aggravate the veteran's obesity? If so, is the Veteran's obesity a substantial factor in causing her current OSA? Would the Veteran's OSA not have occurred but for her obesity caused by or aggravated by her service-connected PTSD? 5. Schedule the Veteran for a VA examination for her peptic ulcer disease (PUD). The examiner must review the claims file. All necessary diagnostic tests and/or diagnostic imaging should be conducted, and the examiner should review those results prior to providing an opinion. The examiner is asked to provide a response to the following: Is the Veteran's PUD at least as likely as not related to service, to include her testimony of stomach problems diagnosed as gastritis while on active duty and as seen in the November 1980 entry in STR, have continued since then? Is the Veteran's PUD, a chronic disease, at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? Is the Veteran's PUD at least as likely as not proximately due to service-connected PTSD or at least as likely as not proximately due to her service-connected anemia? Is the Veteran's PUD at least as likely as not aggravated, i.e., worsened beyond its natural progression, by her service-connected PTSD or at least as likely as not aggravated, i.e., worsened beyond its natural progression by her service-connected anemia? Provide a thorough rationale to support each opinion as the Board is precluded from making medical determinations. T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Nelson 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.