Citation Nr: A25035144 Decision Date: 04/16/25 Archive Date: 04/16/25 DOCKET NO. 240326-425652 DATE: April 16, 2025 REMANDED Service connection for a urinary disability, to include urinary frequency, is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Navy from March 1994 to April 1996, to include service in the Southwest Asia theater of operations, and his decorations include the Southwest Asia Service Medal. This matter is before the Board of Veterans' Appeals (Board) on appeal from an August 2023 Appeals Modernization Act (AMA) rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In the March 2024 VA Form 10182 (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the August 2023 agency of original jurisdiction (AOJ) decision, which was later subject to a higher-level review in December 2023. 38 C.F.R. § 20.301. If evidence was submitted during the period after the AOJ issued the decision, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.301, 20.801. However, because the Board is remanding the claim of urinary frequency, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii). Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. Service connection for urinary frequency is remanded. The Veteran seeks service connection for a urinary disability, to include urinary frequency. In a June 2023 Statement in Support of Claim, the Veteran stated that, after his sleep apnea diagnosis, he noticed that he tends to wake more frequently with a need to urinate and that he has also noticed that he now leaks and/or dribbles. In addition, the Veteran seeks service connection for this condition on the basis that it manifested coincident to his military service and has been recurrent since that time. After a review of the record, the Board determines that a remand is necessary to correct a pre-decisional duty to assist error, as the medical examination and opinion of record is inadequate to adjudicate the claim. 38 C.F.R. § 20.802(a). In a July 2023 VA examination, the VA examiner stated that the Veteran did not have a urinary tract condition of the bladder. The examiner opined that, although the Veteran reports having urinary frequency during daytime and nighttime, there is a lack of objective evidence on the claim files and on the day of the exam for a urinary frequency condition. During the July 2023 VA examination, the Veteran reported that he experienced urinary frequency during service. He reported that, during service, he went to his primary care physician, who referred him to see a urologist. The Veteran further reported that this condition has remained the same over the years and worsened this year. The Board notes that VA Medical Center (VAMC) records document that the Veteran received care for kidney stones in December 2019 and had abnormal urinalysis levels in November 2020. Additionally, in September 2018, the Veteran was prescribed medication for burning urination, and, in a prior October 2017 note, the Veteran was treated for a urinary tract infection. The Board notes that a medical opinion is only adequate "where it is based upon consideration of the Veteran's prior medical history and examinations." Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (quoting Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). And while an examiner is not required to consider every piece of favorable evidence, the examiner must rely on an accurate factual history. Monzingo v. Shinseki, 26 Vet. App. 97, 105-106 (2012), overruled on other grounds by Euzebio v. McDonough, 989 F.3d 1305 (Fed. Cir. 2021); see also Ardison, 6 Vet. App. at 407. Here, the examiner did not acknowledge or discuss the Veteran's pertinent medical history, rendering the VA examination report inadequate for rating purposes. Stefl, 21 Vet. App. at 123; see also See Miller v. Wilkie, 32 Vet. App. 249 (2020) (finding the proper remedy is to order a new examination when an examiner fails to address the veteran's lay statements and reports of symptoms). Further, the Veteran's VAMC records document, the Veteran was treated on multiple occasions for either kidney stones or urinary tract infections. In light of the foregoing, the Board finds that the July 2023 VA examination is inadequate and that a new examination must be obtained. The appeal is remanded for a VA examination that takes into consideration the Veteran's full and accurate medical history. See 38 C.F.R. § 20.802(a); see also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Furthermore, the Board notes that a Veteran of the Persian Gulf War can establish entitlement to service connection on a presumptive basis if the Veteran "exhibits objective indication of a qualifying chronic disability." See 38 U.S.C. § 1117(a); 38 C.F.R. § 3.317(a)(1)(i). Under the regulation, a "qualifying chronic disability" includes a chronic disability that resulted from an "undiagnosed illness." 38 C.F.R. § 3.317 (a)(2)(i)(A). Neurological or neuropsychological signs or symptoms are listed as "signs or symptoms which may be manifestations of undiagnosed illness." 38 U.S.C. § 1117(g)(6)-(7); see Joyner v. McDonald, 766 F.3d 1393, 1395 (Fed. Cir. 2014) (holding that the Board must consider the potential application of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 in all claims for service connection made by Veteran's who served in the Persian Gulf during the Persian Gulf War."); 38 C.F.R. § 3.317 (b)(6)-(7). The matters are REMANDED for the following action: Schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to determine the nature, onset, and etiology of the Veteran's urinary disability, or any qualifying chronic disability under 38 C.F.R. § 3.317. The examiner should review the entire claims file, conduct all necessary tests and studies, to include psychological and neurological examinations, and report all findings in detail. The examiner must acknowledge and discuss the Veteran's competent and credible lay account of his daytime and nighttime urinary frequency since service, i.e., the onset of the urinary frequency was while the Veteran was on active duty. Based on the results of the examination, the examiner is asked to address the following questions: (a) Whether it is at least as likely as not that any diagnosed urinary disability had its onset in or are otherwise related to active service, including service in the Southwest Asia theater of operations. The examiner is to address and consider the Veteran's statements. (b) Whether it is at least as likely as not that any diagnosed disorder manifested itself in the first post-service year. (c) Whether it is at least as likely as not that a urinary disability is due to or aggravated by a service-connected disability. (d) Whether it is at least as likely as not that a urinary disability is due to any TERA established. 38 U.S.C. § 1168(a). (e) If a nexus to his service cannot be established for any abnormality, please provide an opinion as to whether the disability pattern is consistent with: (i) an undiagnosed illness, (ii) a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, (iii) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (iv) a disease with a clear and specific etiology and diagnosis. (f) If, after reviewing the claims file, you determine that the Veteran's disability pattern is consistent with either (iii) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (iv) a disease with a clear and specific etiology and diagnosis, then please provide a medical opinion as to whether it is at least as likely as not that the disability pattern or diagnosed disease is related to environmental exposures experienced by the Veteran during his service in the Southwest Asia theater of operations. A fully articulated medical rationale for any opinion expressed must be set forth in the medical report. The VA medical opinion provider should discuss the particulars of this Veteran's medical history and relevant medical science as applicable to this case, which may reasonably explain the medical guidance in the study of this case. STEVEN D. REISS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Mountjoy, 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.