Citation Nr: 22012278 Decision Date: 03/03/22 Archive Date: 03/03/22 DOCKET NO. 16-46 338 DATE: March 3, 2022 REMANDED Entitlement to service connection for a bilateral knees condition, to include as due to Gulf War illness, is remanded. Entitlement to service connection for a bilateral shoulder condition, to include as due to Gulf War illness, is remanded. Entitlement to service connection for a neck condition, to include as due to Gulf War illness, is remanded. Entitlement to service connection for a bilateral ankle condition, to include as due to Gulf War illness, is remanded. Entitlement to service connection for Reiter's syndrome, claimed as arthritis, to include as due to Gulf War illness, is remanded. Entitlement to service connection for a low back condition, to include as due to Gulf War illness, is remanded. Entitlement to service connection for uveitis, to include as due to Gulf War illness, is remanded. Entitlement to service connection for erectile dysfunction (ED), to include as due to Gulf war illness, and/or as secondary to service-connected diabetes and/or hypertension, is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1989 to October 1991, including service in Southwest Asia. This matter is before the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board has issued two prior remands on these claims in December 2018 and August 2021. 1. Entitlement to service connection for a bilateral knees condition, to include as due to Gulf War illness, is remanded. 2. Entitlement to service connection for a bilateral shoulder condition, to include as due to Gulf War illness, is remanded. 3. Entitlement to service connection for a neck condition, to include as due to Gulf War illness, is remanded. 4. Entitlement to service connection for a bilateral ankle condition, to include as due to Gulf War illness, is remanded. 5. Entitlement to service connection for Reiter's syndrome, claimed as arthritis, to include as due to Gulf War illness, is remanded. 6. Entitlement to service connection for a low back condition, to include as due to Gulf War illness, is remanded. 7. Entitlement to service connection for uveitis, to include as due to Gulf War illness, is remanded. 8. Entitlement to service connection for ED, to include as due to Gulf war illness, and/or as secondary to service-connected diabetes and/or hypertension, is remanded. In the August 2021 Board remand, the RO was instructed to update the record and obtain new VA examinations and opinions for each of the Veteran's claimed conditions. Specifically, the Board requested an opinion on the nature and etiology of the Veteran's genetic autoimmune disorder, including whether it was a congenital defect or congenital disease for VA purposes. Based on this opinion, the examiner was instructed to answer several additional questions regarding the Veteran's other conditions, including whether they were aggravated. In September 2021 several new VA examinations and opinions were uploaded into the Veteran's electronic claims file. The Veteran was noted to have HLA B-27, which the examiner opined was a congenital defect for VA purposes. As rationale for this opinion, the examiner provided "Research has shown more than 9 out of 10 people carry the HLA B27." The Board finds this rationale to be inadequate because it provides no explanation for the conclusion reached. Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr v. Nicholson, 21 Vet. App. 303 (2007). Moreover, in a previous VA examination for the Veteran's uveitis, in answering whether the condition was a disease with clear and specific etiology and diagnosis, the examiner noted "The Veteran is HLAB27 positive, which is a genetic variant. HLAB27 associated uveitis is a recurrent condition that is often more severe and persistent than idiopathic anterior uveitis. It also has a strong association with several systemic conditions. These conditions include, but are not limited to ankylosis spondylitis, Reiter's syndrome, reactive arthritis, inflammatory bowel disease. Until the patient is tested for HLAB27 associated disorders, I cannot answer this question. I was unable to find in the records that he has been tested for these." The Board notes that the most recent examiner has also failed to provide a diagnosis for the Veteran's genetic autoimmune disease. Accordingly, remand is warranted to obtain an addendum opinion regarding the nature and etiology of the Veteran's genetic autoimmune disease and its relationship to his other claimed conditions. Additionally, in opining that the Veteran's autoimmune disorder did not aggravate the Veteran's neck, shoulders, back, knees, and ankles, the September 2021 examiner provided contradictory statements including "It is less likely than not (less than 50% probability) that any increase in disability was due to the natural progression of the preexisting condition." and "Degenerative arthritis of the back is less likely than not (less than 50 percent probability) resulted in an additional disability of the back." On remand, such statements must be clarified. The Board also notes that the September 2021 examiner failed to provide opinions regarding whether the Veteran's joint pain of the neck, shoulders, back, knees, and ankles were attributable to a diagnosed condition as was instructed in the August 2021 Board remand directives. He also failed to provide a direct opinion regarding the Veteran's low back pain which the Veteran contends began during his active service after lifting. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding remand by the Board confers on the claimant the right to compliance with the remand requests). Accordingly, addendum opinions regarding these conditions will also be obtained on remand. Finally, the Board notes that the Veteran is service connected for both diabetes and hypertension due to his service in Southwest Asia, both of which are known to cause ED. The record does not contain any clear opinions regarding secondary service connection for the Veteran's ED. Accordingly, remand is warranted to obtain an addendum opinion regarding whether the Veteran's ED was caused or aggravated by either his service-connected diabetes or hypertension. The matters are REMANDED for the following action: 1. Update the electronic file with any new VA treatment records and private treatment records. 2. Obtain an addendum opinion regarding the nature and etiology of the Veteran's genetic autoimmune disorder by a rheumatologist, M.D. The examiner must review the claims file and a note that such was reviewed should be included in his or her report. Following a review of the record, the examiner should respond to the following: (a.) Has the Veteran been tested for HLAB27 associated disorders? If so, what autoimmune disorder(s) has the Veteran been diagnosed with? (b.) Is/are the Veteran's autoimmune disorder(s) considered to be a congenital defect (more or less static in nature) or congenital disease (capable of improving or deteriorating) for VA purposes? (The examiner is advised that for the purposes of VA compensation, a "congenital defect" or abnormality is defined as a condition that is more or less stationary in nature, whereas a "congenital disease" is defined as a condition capable of improving or deteriorating.) (c.) If the autoimmune disorder is a congenital defect, is it at least as likely or not (a 50 percent probability or greater) that there was a superimposed disease or injury in-service that resulted in an additional disability of the neck, shoulders, back, knees and ankles? (d.) If the autoimmune disorder is a congenital disease, is it clear and unmistakable that it manifested prior to service? Is it clear and unmistakable that it was not aggravated in service? Please determine whether it is clear and unmistakable that there was no increase during service, or that it is clear and unmistakable that any increase in disability was due to the natural progression of the pre-existing condition. (e.) Identify all neck, shoulders, back, knees and ankle conditions that were diagnosed during the appeal period, to specifically include degenerative or traumatic arthritis. For each diagnosed disability, the examiner should state whether it is at least as likely as not (50 percent or greater probability) that such was incurred during active service or is otherwise related to the Veteran's military service. The examiner is reminded that a medical opinion based solely on the absence of documentation in the record or that does not address the Veteran's reports of symptoms and history is inadequate. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A complete rationale is requested for any opinion expressed. If the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion would be speculative. 3. Obtain an addendum opinion regarding the nature and etiology of the Veteran's claimed symptoms of joint pain, to include neck, shoulders, back, knees, and ankles pain. The examiner must address whether the claimed symptoms of joint pain, to include neck, shoulders, back, knees, and ankles pain, are attributable to a diagnosed condition. If the symptoms are attributable to a diagnosed condition, the examiner must then discuss both the etiology and pathophysiology of the condition to which the Veteran's reported symptoms have been attributed with 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. If any of the claimed symptoms are attributable to a diagnosed condition with both an etiology and pathophysiology that are at least partially understood in the context of the Veteran's unique circumstances, the examiner must then address whether the condition is at least as likely as not (50 percent probability or greater) the result of disease or injury in active service. The examiner is reminded that a medical opinion based solely on the absence of documentation in the record or that does not address the Veteran's reports of symptoms and history is inadequate. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A complete rationale is requested for any opinion expressed. If the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion would be speculative. 4. Obtain an addendum opinion regarding the nature and etiology of the Veteran's low back disorder. The examiner must review the claims file. The examiner must opine whether the Veteran's back disability is at least as likely as not related to service, including the Veteran's reported lifting injury during service. The examiner is reminded that a medical opinion based solely on the absence of documentation in the record or that does not address the Veteran's reports of symptoms and history is inadequate. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A complete rationale is requested for any opinion expressed. If the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion would be speculative. 5. Obtain an addendum opinion regarding the nature and etiology of the Veteran's uveitis. The examiner must review the claims file and must opine whether it is at least as likely as not that the Veteran's uveitis is related to his service, including his service in Southwest Asia. The examiner should also opine whether the Veteran's uveitis is a diagnosed disability with at least a partially understood pathophysiology AND etiology. The examiner should also opine whether the Veteran's uveitis was aggravated beyond its natural progression by the Veteran's genetic autoimmune disorder(s). The examiner is reminded that a medical opinion based solely on the absence of documentation in the record or that does not address the Veteran's reports of symptoms and history is inadequate. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A complete rationale is requested for any opinion expressed. If the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion would be speculative. 6. Obtain an addendum opinion regarding the nature and etiology of the Veteran's erectile dysfunction. The examiner must review the claims file and must opine whether it is at least as likely as not that the Veteran's erectile dysfunction was caused or aggravated by either his service-connected diabetes or hypertension. The examiner is reminded that a medical opinion based solely on the absence of documentation in the record or that does not address the Veteran's reports of symptoms and history is inadequate. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A complete rationale is requested for any opinion expressed. If the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion would be speculative. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Ruiz, Associate 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.