Citation Nr: 18160605
Decision Date: 12/27/18	Archive Date: 12/27/18

DOCKET NO. 15-38 257
DATE:	December 27, 2018
REMANDED
Entitlement to service connection for fibroids or residuals thereof is remanded.
Entitlement to service connection for melanoma on the neck, to include residual neck scars, status-post excision, is remanded.
Entitlement to service connection for a headache disability is remanded.
Entitlement to an initial rating higher than 10 percent for residuals of a gallbladder surgery is remanded.
REASONS FOR REMAND
The Veteran served on active duty form January 1987 to September 2008.
In February 2017, the Veteran withdrew her previous request for a Board hearing.  
As reflected above, the Board rephrased the service connection issues for fibroids and melanoma to more closely align with the contentions expressed by the Veteran.
The Board finds that a remand is necessary to provide the Veteran with new VA examinations.
Fibroids
The Veteran underwent a VA examination in July 2013, at which time the examiner opined that the “residuals of cervical cancer and fibroids, which was diagnosed as menorrhagia with anemia status-post hysteroscopy, polypectomy, endometrial ablation, was not caused by her abnormal pap smear and cervical biopsy that occurred in November 1988 and May 1990 during service.  The examiner explained that it likely was caused by endometrial polyp, which was also not caused by neither abnormal pap nor the cone biopsy. 
In support of her claim, the Veteran submitted a June 2018 opinion authored by Dr. Ali, a private physician specializing in internal medicine, pain and palliative care/hospice, and wound care, who stated that the Veteran developed abnormal vaginal bleeding while in service.  The physician identified multiple potential causes of abnormal vaginal bleeding, to include cervical cancer, diffuse leiomyomatous uterus, and uterine fibroid.  The physician challenged the July 2013 VA opinion, asserting that the examiner failed to address the Veteran’s cervical cancer and leiomyomatous uterus diagnoses and their relation to abnormal vaginal bleeding.  
The issue of entitlement to service connection for residuals of cervical cancer was denied in a September 2013 rating decision and was not appealed by the Veteran.  In other words, she is not service-connected for residuals of cervical cancer.  
At any rate, although Dr. Ali and the VA examiner possess medical training, the Board finds that the question as to etiology would best be provided by a medical examiner who specializes in gynecology.  As such, the Board finds that a new VA examination is necessary. 
Melanoma on the Neck
Dr. Ali, in the June 2018 opinion, opined that the Veteran’s melanoma on her neck was caused by UV light exposure during her active duty service.  Dr. Ali felt that the Veteran was misdiagnosed during service because a biopsy was the only way to establish definite diagnosis.  While acknowledging that she possesses some degree of medical training in dermatology, the Board finds that a medical examiner specializing in dermatology would be best to address the etiology of the Veteran’s melanoma.
In light of the record, a VA skin examination is necessary.  The Veteran has not yet been afforded a VA compensation examination in connection with the melanoma claim.   
Headache Disability
During a July 2013 VA examination for headaches, the examiner diagnosed tension headaches and opined that the Veteran’s tension headaches are less likely related to the migraine headaches treated in service, as they have different etiologies.  The examiner also noted that the Veteran’s migraine headaches that were diagnosed during service had since resolved with no residuals.  
To the contrary, Dr. Ali, in her June 2018 opinion, suggests that the Veteran has current migraine headaches that are related to service.  The physician noted that the Veteran developed migraine headaches in service and determined that the Veteran’s certain complaints of migraine headaches in service were misdiagnosed as viral illnesses.  
First, the current record is unclear as to whether the Veteran currently has migraine headaches.  Her medical treatment notes are limited and the claims file does not contain any relevant treatment notes after the July 2013 examination during which it was noted that the headaches had resolved.  Updated treatment records are needed.  Second, although the examiner opined that the Veteran’s tension headaches are not related to the migraine headaches diagnosed in service, the examiner did not address whether the tension headaches are otherwise related to service.  Accordingly, a new examination is necessary.
Increased Rating for Residuals of a Gallbladder Surgery
The Veteran was provided with a VA examination for gallbladder and pancreas conditions in July 2013 in connection with her service connection claim.  Subsequently, she reported that her symptoms have worsened since that time and now include symptoms of gastroesophageal reflux disease (GERD).  Given the indication of a worsening of her residuals of gallbladder surgery, a new examination is necessary.  See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995).
The matters are REMANDED for the following action:
1.  Ensure that all outstanding VA treatment records since 2013 are associated with the claims file.  
2.  Invite the Veteran to submit any relevant private treatment records and provide her with the necessary authorization/consent forms to do so.
3.  Then, provide the Veteran with a VA gynecological examination by an appropriate medical professional to determine the nature and etiology of any fibroids or residuals thereof.  If possible, the requested opinions should be answered by a medical provider specializing in gynecology.  The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials.
After a careful review of the claims file and examination of the Veteran, the examiner is asked to respond to the following:
(a) Identify any fibroids or residuals thereof since the date of claim in March 2012. 
(b) Opine whether any current fibroids or residuals thereof, at least as likely as not (50 percent probability or higher), had their onset during active duty service.  Specific attention is called to: STRs documenting abnormal bleeding; a 1988 cone biopsy showing evidence of cervical cancer CIN III; fibroids shown on ultrasound, and a diffuse leiomyomatous uterus.  
(c) Address the June 2018 private opinion provided by Dr. Ali and associated medical literature.  See VBMS entry titled “correspondence” on 08/06/2018. 
A complete rationale should be provided for all opinions.
4.  Provide the Veteran with a VA skin examination to determine the nature and etiology of her residual scars, status-post melanoma on the neck.  If possible, the requested opinions should be answered by a medical provider specializing in dermatology.  The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials.
After a careful review of the claims file and examination of the Veteran, the examiner is asked to respond to the following:
(a)  Identify any melanoma and/or residual scars on the neck post-melanoma excision since the 2012 date of claim. 
(b) For any current melanoma or residual scars on the neck, provide an opinion as to whether it is at least as likely as not (50 percent probability or higher) had their onset during active duty service as a security forces member (military police).
*Attention is called to the following: (i) Veteran’s contention that she had no moles upon service entry and noticed a mole toward the end of her service; (ii) she contends that UV light exposure while on base patrol duty for 10-12 hours for years caused the melanoma; (iii) September 2013 statement from ex-spouse who observed the mole during service; and (iv) Report Documentation Page that highlights a journal submission titled, “Melanoma Incidence Rates in Active Duty Military Personnel Compared with Population-Based Registry in the United States, 2000-2007.”
(c) In answering the opinion request, specifically address the June 2018 private opinion by Dr. Ali (and associated medical literature) linking the Veteran’s melanoma to UV light exposure in service and asserting that the Veteran’s melanoma diagnosis was missed during service because a biopsy was not conducted.  See VBMS entry titled “correspondence” on 08/06/2018.
A complete rationale should be provided for all opinions.
5.  Provide the Veteran with a VA examination by an appropriate medical professional to determine the nature and etiology of her claimed headache disability.  The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials.

After a careful review of the claims file and examination of the Veteran, the examiner is asked to respond to the following:
(a) Elicit from the Veteran all sign and symptoms of her headaches in service and since separation from service.
(b) Clearly indicate whether the Veteran has had tension and migraine headaches since the March 2012 date of claim.  
(c) Provide an opinion as to whether the tension headaches diagnosed on July 2013 VA examination (and any subsequent ones) had their onset during active duty service.  
(d) If migraine headaches have been diagnosed since the date of claim, provide an opinion as to whether the migraine headaches had their onset during service.  
Attention is called to: the STRs showing treatment for headaches, and the contention by Dr. Ali that the Veteran’s symptoms in service were misdiagnosed as viral illness rather than migraine headaches.  See Dr. Ali’s June 2018 opinion with associated medical literature.  See VBMS entry titled “correspondence” on 08/06/2018.
A complete rationale should be provided for all opinions.
6.  Provide a VA examination by an appropriate medical professional to determine the current severity of service-connected residuals of the Veteran’s gallbladder surgery.  The claims file must be made available to and be reviewed by the examiner.  All necessary tests and studies should be accomplished and all clinical findings reported in detail.
After a review of the claims file and examination of the Veteran, the examiner is asked to respond to the following: 
(a)	Identify all current residuals of the Veteran’s gallbladder removal.  Indicate whether her symptoms are mild or severe in nature, and explain why.
(b)	Address the Veteran’s reports of GERD.  Specifically indicate whether any current GERD is related to the gallbladder removal.  If so, clearly identify the symptoms of the GERD, and indicate any overlapping symptoms.
Attention is called to the medical literature submitted by the Veteran.  See VBMS entries titled “correspondence” and “medical treatment record – non-government facility” on 10/23/2015. 
A complete rationale should be provided for all opinions.
(Continued on the next page)
 
7.  Thereafter, readjudicate the claims on appeal.
 
S. B. MAYS
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	A. Yaffe, Associate Counsel

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