Citation Nr: 1313656 Decision Date: 04/24/13 Archive Date: 05/03/13 DOCKET NO. 11-00 921 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE Entitlement to service connection for a left hand disability, to include as secondary to a service-connected fragmentation wound, left elbow. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD D. Johnson, Counsel INTRODUCTION The Veteran served on active duty from December 1965 to December 1967. This matter is before the Board of Veterans' Appeals (Board) on appeal of a July 2010 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran requested a hearing on his January 2011 substantive appeal form, but subsequently withdrew his hearing request. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran seeks service connection for a left hand disability that is manifested by symptoms of numbness, tingling, and loss of sensation and feeling in his hand and fingers. He contends that this disability is related to his service-connected fragmentation wound, left elbow. In a letter received in August 2010, a VA physician stated that Dr. Romanowsky (a private neurologist at CentraCare Health Systems) had performed an electromyography study (EMG) on the Veteran; the results of which confirmed compression of the nerves in the Veteran's left wrist and elbow (i.e., carpal tunnel syndrome and ulnar neuropathy). VA treatment records contain references to medical records from Dr. Romanowsky dated in 2010, as well as an EMG study, but there are no such records in the claims file or available via Virtual VA. To ensure that VA has met its duty to assist pursuant to 38 U.S.C.A. § 5103A, the claim must be remanded so that the missing private treatment records from Dr. Romanowsky can be located and associated with the claim file. The Veteran was afforded a VA examination in June 2010. The examiner diagnosed left hand weakness with associated numbness and opined that this diagnosis was not secondary or related to the service-connected left elbow fragment wound. The rationale was that an August 2008 VA examination report showed normal sensation and strength upon examination of both upper extremities, and a June 2010 clinical note indicated the Veteran had had a stroke (with residual weakness and numbness in the left upper extremity likely representing a small completed right cerebral infarct). In an addendum received in September 2011, the same examiner opined that the Veteran's left carpal tunnel syndrome and ulnar neuropathy are not due to or aggravated by the service-connected left elbow fragment wound because the August 2008 VA examination report showed a positive Tinel's sign at the bilateral elbows and wrists. The examiner's opinions lack fully-explained rationales and are insufficient for purposes of adjudicating this claim. The June 2010 opinion and rationale seems to suggest that the Veteran's left extremity symptoms were related to his stroke in April 2010. However, the Veteran's symptoms of tingling in his left hand and numbness along the tips of his fingers were first reported in January 2008 -even though the physical examination showed normal strength and sensation. The examiner did not provide any discussion of the clinical significance, if any, of the symptoms reported in 2008 two years prior to his stroke. The September 2011 rationale is merely a recitation of the August 2008 findings without any supplemental explanation or discussion of the clinical evidence. Furthermore, it is unclear whether the VA examiner had an opportunity to review the private neurology records and EMG study conducted by Dr. Romanowsky because these records have not yet been associated with the claims file. A medical nexus opinion that is based on all of the pertinent evidence and supported by a thoroughly explained rationale is required for adjudication. See Nieves-Rodriguez, 22 Vet. App. 295 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The case is remanded for this purpose. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and his representative and request that they provide sufficient information, and if necessary, authorization, to enable the RO to obtain any additional evidence pertinent to the claim on appeal. After securing the necessary authorizations for release of this information, obtain copies of all records from Dr. Romanowsky, including his June 2010 and August 2010 notes and the EMG report. Any negative response must be in writing and associated with the claims file. 2. Schedule the Veteran for a VA neurologic examination by an appropriate medical professional. The entire claims file (i.e., the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be reviewed by the examiner. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. The examiner is to state whether the Veteran currently has bilateral carpal tunnel syndrome and ulnar neuropathy, or if these diagnoses are limited to the left upper extremity only. The examiner is to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that carpal tunnel syndrome and/or ulnar neuropathy affecting the left upper extremity is related to service; or whether it is caused or aggravated by the service-connected fragmentation wound, left elbow. The examiner is advised that the term "aggravation" means a permanent increase in the claimed disability; that is, an irreversible worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 3. Review the claims file to ensure that all of the foregoing development has been completed. Then readjudicate the claim on appeal. If the benefit remains denied, issue an appropriate supplemental statement of the case and provide the Veteran and his representative an appropriate period of time to respond. The case is to then be returned to the Board for further appellate review. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ RONALD W. SCHOLZ Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).