Citation Nr: 24034167 Decision Date: 12/11/24 Archive Date: 12/11/24 DOCKET NO. 15-16 184 DATE: December 11, 2024 REMANDED Entitlement to service connection for a skin condition, to include vitiligo, is remanded. Entitlement to an initial rating in excess of 10 percent for allergic rhinitis (rhinitis) is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from November 1990 to May 1991. She also had a period of active duty for training (ACDUTRA) from February 1980 to June 1980. The issue comes before the Board of Veterans' Appeals (Board) on appeal from a July 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in June 2018. A transcript of the hearing has been included with the record. The issue was previously remanded by the Board for further development in September 2018. In April 2023, the Board denied entitlement to service connection for the Veteran's skin condition and for an initial rating in excess of 10 percent for the Veteran's service-connected rhinitis. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In November 2023, the Court granted a Joint Motion for Partial Remand (JMPR), vacating and remanding the matter to the Board. The parties to the JMPR agreed that the Board erred in not addressing whether a separate rating for sinusitis was warranted and erred in not providing an adequate statement of reasons or bases for whether the Veteran's skin condition constituted a medically unexplained chronic multisymptom illness (MUCMI). The Board consequently remanded the matter to the RO in January 2024 in accordance with the November 2023 JMPR. While the Board regrets further delay, another remand is necessary to ensure substantial compliance with the January 2024 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for a skin condition, to include vitiligo The Veteran contends that her current skin condition is due to her active-duty service, to include as due to toxic exposure. When VA provides an examination, it must be an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). An adequate evaluation is one where the examiner's opinion is based upon consideration of the Veteran's prior medical history and describes the disability in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one. Inadequate examinations and opinions include those that provide insufficient supporting rationale or contain only data and conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Further, VA has a duty to provide the veteran a thorough medical examination, one which takes into account the veteran's prior medical history and describes the disability in sufficient detail so that the Board's evaluation of the claimed disability is fully informed. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A VA examination must contain clear conclusions with supporting data, and a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). In the November 2023 Joint Motion for Partial Remand, the parties agreed that the Board erred in not providing an adequate statement of reasons or bases for whether the Veteran's skin condition constituted a MUCMI. The parties agreed that a new VA examination could be warranted. The Board found the prior VA medical opinions to be inadequate and remanded the matter in its January 2024 decision for an adequate medical opinion. However, the Board finds that the Veteran's subsequent medical opinion to also be inadequate, and that another remand is required. After the last January 2024 Board remand, the Veteran underwent another VA examination in February 2024, where several nexus opinions were provided. The examiner found that the Veteran had vitiligo and no other skin conditions. The examiner conducted a records review. Regarding toxic exposure risk activity (TERA), the examiner noted that the Veteran reported daily exposure to burn pits and other toxins (BPOT) without use of personal protective equipment (PPE). She also stated that no medical science supports a finding relating the Veteran's vitiligo to her TERA, but also that no risk factors outside of her military service were found. The examiner found that the vitiligo was a diagnosable chronic multi-symptom illness with a partially explained etiology, but concluded that it was less likely than not that the Veteran's vitiligo was due to her active-duty service, including a confirmed TERA. See December 2022 VA memorandum. Regarding any other skin condition, the examiner found that the Veteran had no other diagnosis for a skin condition and therefore concluded that it was less likely than not that the Veteran had another skin condition that was attributable to service, including TERA. The examiner did not adequately address the Veteran's in-service symptoms or all her current symptoms. The Veteran reported rash on her skin and arms while in service. See June 1993 and November 1993 service treatment records (STRs). Further, the Veteran reported, "... I returned from deployment with several symptoms, that no one has been able to diagnose. Those symptoms include: fatigue, joint pain, headaches, psychological, skin rash, memory loss, and sleep disturbances." See October 2013 Notice of Disagreement. Thus, to the extent that the examination did not include the Veteran's lay statements and entire disability picture sufficient to allow the Board to make an informed decision on the issue, it is inadequate. Barr, 21 Vet. App. at 311; see also, Nieves-Rodriguez, 22 Vet. App. at 304. Further, although the examiner found that the Veteran's vitiligo was of partially explained etiology, she did not address whether the Veteran's disability had at least a partially understood pathophysiology, which could affect the outcome of the matter. A medically unexplained chronic multisymptom illness (MUCMI) is defined as a "diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities." 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a)(2)(ii) (emphasis added). "Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained." Id. Absent an adequate medical opinion addressing the causal nexus between the Veteran's active service and skin condition, to include vitiligo, the record is insufficient for the Board to decide on the Veteran's claim, and a remand is needed. 2. Entitlement to an initial rating in excess of 10 percent for rhinitis The Veteran contends that an initial rating in excess of 10 percent is warranted for her service-connected rhinitis. When VA provides an examination, it must be an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). An adequate evaluation is one where the examiner's opinion is based upon consideration of the Veteran's prior medical history and describes the disability in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one. Inadequate examinations and opinions include those that provide insufficient supporting rationale or contain only data and conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In the January 2024 decision, the Board found that the Veteran's prior medical opinions were inadequate to determine the appropriate rating for the Veteran's rhinitis, including in consideration of any symptoms of sinusitis. In her October 2013 NOD, the Veteran stated that she believed the correct diagnosis for her service-connected disability should be sinusitis. See October 2013 NOD. She went on to state that she experienced more than six non-incapacitating episodes per year, for which she self-treated with over-the-counter medications. Id. The Veteran also testified at the June 2018 Board hearing regarding her allergic rhinitis. She stated that she experienced symptoms daily, including headaches and dizziness, for which she took medications. The Veteran previously indicated in the NOD that she experienced more than six non-incapacitating episodes of sinusitis a year, but she made no mention of sinusitis during the June 2018 hearing. Moreover, although the Veteran previously indicated that she thought a rating for sinusitis was appropriate, she did not distinguish her symptoms between sinusitis or rhinitis in her June 2018 Board hearing testimony. See October 2013 NOD; see also, June 2018 hearing transcript. The Veteran has been experiencing sinusitis from service through the present day. Her STRs contain the Veteran's prolonged sinusitis symptoms. See February and March 1991 STRs. She has also had sinusitis after service as well as more recently. See January 2019 private treatment records. In the November 2023 JMPR, the parties agreed that the Board erred in not determining whether a separate rating for sinusitis was warranted, given that it was reasonably and explicitly raised by the record. The Veteran consequently underwent another VA examination in February 2024, in which a records review was conducted. However, the examiner did not discuss the Veteran's sinusitis diagnosis or symptoms in the examination as requested in the January 2024 Board remand directives. Thus, to the extent that the VA examination did not include the Veteran's entire disability picture, including the Veteran's medical record and lay statements, sufficient to allow the Board to make an informed decision on the issue, it is inadequate. Barr, 21 Vet. App. at 311; see also, Nieves-Rodriguez, 22 Vet. App. at 304. For these reasons, the Board finds that a new VA examination is needed to determine the appropriate rating for the Veteran's service-connected rhinitis, to include whether a separate rating is warranted for sinusitis. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination with an appropriate examiner to determine the etiology of the Veteran's claimed skin condition. The record and a copy of this Remand must be made available to the examiner. The examination may be conducted via telehealth or similar service. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail, and correlated to a specific diagnosis. Following a review of the evidence of record, the examiner must opine as to whether: (a) it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's skin condition had its onset during, or is otherwise etiologically related to, active-duty service, to include whether it is a medically unexplained chronic multisymptom illness (MUCMI) related to the Veteran's Persian Gulf service. (b) it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's skin condition is due to in-service associated toxic exposure. Under the PACT Act, as stated above, the Veteran has established military service that qualifies for a presumption of environmental exposure, and the examiner must consider the total potential exposure through all applicable military deployments and service and conduct a synergistic and combined effect analysis of all toxic exposure risk activities that may provide a basis to service connect the claimed disability. The examiner must provide a comprehensive report including a clearly stated rationale for any opinions offered and conclusions reached, citing the objective medical findings leading to the conclusions, and must not be based solely on the lack of records. In this regard, the Board emphasizes that the Veteran is competent to report her symptoms and history, and such statements by the Veteran regarding symptomatology and medical history must be specifically acknowledged and considered in formulating any opinions concerning the onset and severity of her disability. If such reports are rejected by the examiner, a reason for doing so must be provided. A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved should be included. 2. Schedule the Veteran for a VA examination with an appropriate examiner to determine the current severity of the Veteran's allergic rhinitis, to include consideration of the Veteran's sinusitis. The record and a copy of this Remand must be made available to the examiner. The examination may be conducted via telehealth or similar service. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail. The examiner must provide a full description of the disability for both the Veteran's allergic rhinitis and sinusitis and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria for both allergic rhinitis and sinusitis, to include consideration of the Veteran's lay statements and descriptions of her incapacitating and non-incapacitating episodes. JENNIFER HWA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Matta, Martina Y. 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.