Citation Nr: 25005652 Decision Date: 04/24/25 Archive Date: 04/24/25 DOCKET NO. 15-02 469 DATE: April 24, 2025 REMANDED Entitlement to service connection for an acquired psychiatric disorder, including major depressive disorder, bipolar disorder and posttraumatic stress disorder (PTSD), to include as secondary to service-connected disabilities, is remanded. Entitlement to service connection for hypertension, to include as secondary to service-connected disabilities, is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected disabilities, is remanded. Entitlement to service connection for bilateral carpal tunnel syndrome, to include is secondary to service-connected disabilities, is remanded. Entitlement to service connection for osteoarthritis of the shoulders, elbows, wrists and hips is remanded. Entitlement to a compensable rating for acne scarring on the cheeks and back, furuncle and atopic dermatitis is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1981 to September 1984. He also had a period of active duty for training (ACDUTRA) from September 1987 to February 1988 with the Army National Guard. In October 2018, the Board remanded the issues remaining on appeal. Unfortunately, the Board finds that another remand is necessary in order to comply with prior remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board also remanded the issues of entitlement to service connection for an eye disorder, parathyroid, dysphagia, upper respiratory disorder, diabetes mellitus and peripheral neuropathy. However, service connection for the Veteran's eye disorder was awarded in a May 2022 rating decision and service connection for the remaining issues was awarded in a November 2024 rating decision; representing a full grant of the benefits sought on appeal. Lastly, additional medical evidence, including VA clinical records, have been associated with the claims file that have not been considered by the agency of original jurisdiction (AOJ) with respect to this appeal. However, waiver of AOJ consideration of this evidence is not necessary as the AOJ will have the chance to consider this evidence on remand. Entitlement to service connection for an acquired psychiatric disorder, including major depressive disorder, bipolar disorder and PTSD, to include as secondary to service-connected disabilities, is remanded. The Veteran was afforded a VA Examination in March 2021 to determine the etiology of the Veteran's psychiatric disorder. The examiner found that the Veteran did not meet the criteria for PTSD. The examiner also found that the symptoms or records do not meet the criteria for bipolar disorder. Rather, the examiner diagnosed unspecified depressive disorder and opined that it was not related to service. The examiner rationalized that records show "he reported started with depression after a job accident in 2005 where he resulted with a back injury, was unable to walk for some time, and in general, impacted his life significantly". Currently reported, "can't stand the pain anymore and it has affected all his life, marital and all, other medical problems also, I don't sleep, I can't bend over, I have difficulty walking, the main problem is deformation in my back and dysphagia that is not service-connected, also diabetes". Current depression appeared to manifest in 2005 after an accident, years after, and unrelated to military service. Records suggest depressive features appear to have continued until currently although he has not participated in mental health treatment in recent years. While the examiner found that the Veteran's disorder was not directly related to service, there was some indication of a possible association with the Veteran's now service-connected disorders, including back, dysphagia and diabetes mellitus. In turn, an addendum opinion is necessary to determine whether the Veteran's psychiatric disorder is caused by or aggravated by his service-connected disorders. Entitlement to service connection for hypertension, to include as secondary to service-connected disabilities; entitlement to service connection for erectile dysfunction, to include as secondary to service-connected disabilities; and entitlement to service connection for bilateral carpal tunnel syndrome, to include is secondary to service-connected disabilities, are remanded. The Veteran asserts that his disorders are due to exposure to herbicides, radiation and other contaminants while stationed at Redstone Arsenal during ACDUTRA. Importantly, the Veteran's exposure to radiation and Agent Orange could not be verified on remand. However, after reviewing the claims file, including information concerning contaminants at Redstone Arsenal, the May 2022 VA examiner found that the Veteran's diabetes mellitus and thyroid disorder were due to exposure to other contaminants, primarily PFAS. The AOJ subsequently awarded service connection for these disorders. However, the May 2022 VA examiner found that the Veteran's hypertension, erectile dysfunction and carpal tunnel syndrome were not related to service. To summarize, the examiner rationalized that hypertension, erectile dysfunction and bilateral carpal tunnel syndrome manifested years after discharge and were not related to exposure to contaminants while stationed at Redstone Arsenal. Unfortunately, the examiner failed to further explain why these disorders were not related to such exposure, especially given that the examiner found that the Veteran's diabetes mellitus and other disorders were related to such exposure observing that exposure to PFAS, especially if it is long-term, can lead to the development of numerous serious diseases and health problems. Thus, given the lack of further explanation, this rationale is inadequate. Moreover, the Veteran has also appeared to indicate that these disorders are associated with his diabetes mellitus, type, which is now service-connected. In turn, a secondary opinion is also necessary. Further, importantly, in August 2022, the SFC Heath Robinson Honoring Our Promise to Address Comprehensive Toxins Act of 2022, Pub. L. 117-168, 136 Stat. 1759 ("PACT Act") was passed. Under the PACT Act, certain development is necessary when a Veteran participates in toxic exposure risk activities (TERAs). VA is required to provide a disability examination and medical nexus opinion when a veteran submits a compensation claim and has evidence of a disability and participation (TERAs), but the evidence is not sufficient to establish service connection for the disability. See 38 U.S.C. § 1168 (a) (see PACT Act, Sec. 303). In this case, the Veteran has not been afforded a TERA opinion. Accordingly, in light of the above, these matters must also be remanded for addendum opinions. Entitlement to service connection for osteoarthritis of the shoulders, elbows, wrists and hips is remanded. In its prior October 2018 decision, the Board noted that the May 2017 private examiner diagnosed osteoarthritis of the shoulders, elbows and wrists and opined that the Veteran's severe musculoskeletal disease were more probable than not secondary to his military service. Moreover, VA clinical records also show that the Veteran has been diagnosed with bilateral hip osteoarthritis. The Board remanded this matter to obtain a VA examination with opinion addressing the etiology of the Veteran's osteoarthritis of his various joints. However, the only examination provided pertained to the low back. Thus, this matter must be remanded in order to comply with the prior Board remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to a compensable rating for acne scarring on the cheeks and back, furuncle and atopic dermatitis is remanded. This matter was remanded to afford the Veteran a VA examination to address the severity of the Veteran's skin disorder. The Veteran was afforded VA skin and scar examinations in May 2022. However, while issuing a supplemental statement of the case (SSOC) in November 2024, the AOJ did not readjudicate this issue in the SSOC. As such, in order to avoid any prejudice to the Veteran and to comply with the Board's prior remand, this issue must also be returned to the AOJ for consideration and issuance of a SSOC. 38 C.F.R. § 19.31; Stegall v. West, 11 Vet. App. 268 (1998). The matters are REMANDED for the following action: 1. Obtain an addendum opinion by an appropriate clinician to determine the nature and etiology of the Veteran's psychiatric disorder. The examiner must review the claims file. The need for another examination is left to the discretion of the examiner. The examiner must opine whether any psychiatric disorder is at least as likely as not caused by or aggravated (any incremental increase, regardless of permanence) by service-connected disabilities. The examiner must offer a detailed rationale for their opinions. The examiner must provide separate rationales for both secondary causation and aggravation. The examiner must also consider any causal link between the Veteran's psychiatric disorder and his service-connected disorders. 2. Obtain an addendum opinion by an appropriate clinician to determine the nature and etiology of the Veteran's hypertension, erectile dysfunction and bilateral carpal tunnel syndrome. The examiner must review the claims file. The need for another examination is left to the discretion of the examiner. With respect to each disorder, the examiner should respond to the following: a) Whether it at least as likely as not that such disorder (1) began during active service, (2) manifested within one year after discharge from service, (3) was noted during service with continuity of the same symptomatology since service, or (4) related to an in-service injury, event, or disease, to include the total combined exposure to TERAs through all applicable deployments of the Veteran, as well as the synergistic and combined effect of all TERA, to include conceded exposure at Redstone Arsenal. b) If found to not be directly related to service, whether it is at least as likely as not caused by or aggravated (any incremental increase, regardless of permanence) by service-connected disabilities. The examiner must offer a detailed rationale for their opinions. The examiner must consider service treatment records, post service treatment records, and the Veteran's lay evidence. The examiner should ensure that the examination complies with TERA requirements under the PACT Act. With respect to secondary service connection, the examiner must provide separate rationales for both secondary causation and aggravation. The examiner must also consider any causal link between the Veteran's hypertension, erectile dysfunction and bilateral carpal tunnel syndrome and his service-connected disorders. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any osteoarthritis of the shoulders, elbows, wrists and hips. The examiner must review the claims file. The examiner should clearly delineate all diagnosed disorders of the shoulders, elbows, wrists and hips. The examiner must opine whether it at least as likely as not that any disorders of the shoulders, elbows, wrists and hips (1) began during active service, (2) manifested within one year after discharge from service, (3) was noted during service with continuity of the same symptomatology since service, or (4) related to an in-service injury, event, or disease. The examiner must offer a detailed rationale for their opinions. The examiner must consider service treatment records, post service treatment records, and the Veteran's lay evidence. 4. Readjudicate all of the remaining issues on appeal and issue a SSOC. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.N. Moats, 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.