Citation Nr: 1324479 Decision Date: 08/01/13 Archive Date: 08/13/13 DOCKET NO. 07-31 969 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for peripheral neuropathy. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Veteran and spouse ATTORNEY FOR THE BOARD C.A. Skow, Counsel INTRODUCTION The Veteran served on active duty from October 1966 to October 1968. This matter came before the Board of Veterans' Appeals from a May 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In March 2009, the Veteran and his spouse testified before the undersigned Veterans Law Judge at the RO. A hearing transcript is associated with the record. In May 2009 and November 2011, the Board remanded the claim for further evidentiary development. The Board notes that, in addition to the paper claims files, there is a Virtual VA electronic claims file associated with the Veteran's claim. A review of the documents in the electronic file reveals that they are either duplicative of the evidence in the paper claims files or are irrelevant to the issue on appeal. 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 peripheral neuropathy. In 2009 and 2011, the Board remanded the matter for a VA examination with a medical opinion. The record shows that the Veteran underwent VA examinations in November 2009 and again in January 2012, which confirmed peripheral neuropathy. However, the medical opinions rendered are inadequate. The most recent medical opinion dated in 2011 does not address whether peripheral neuropathy is secondary (caused or aggravated) to service-connected skin disability. Therefore, it is incomplete and does not fully satisfy the terms of the Board's remand. Furthermore, the medical opinion in regards to direct service connection (whether peripheral neuropathy was due to disease or injury incurred in service) is inadequate because the supporting rationale is unexplained. The physician stated simply that "without medical documentation from his time in Vietnam, I would state it is less likely as not that his current symptoms are [a] continuation [of] symptoms from the military." The significance of "medical documentation in Vietnam" is unclear when the Veteran is competent to report his symptoms of pain and numbness. It is noted that a medical opinion must support its conclusion with an analysis the Board can consider and weigh against other evidence in the record. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Furthermore, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Here, medical opinion does not lay out clearly the conclusions with supporting data and a reasoned medical explanation connecting the two. A remand by the Board imposes upon the Secretary of VA a concomitant duty to ensure compliance with the terms of the remand. Where remand orders of the Board are not complied with, the Board errs in failing to insure compliance. Stegall v. West, 11 Vet. App. 268 (1998). Therefore, remand for a new medical opinion is required. Lastly, the Board observes that the Veteran's representative submitted additional evidence with his informal hearing presentation without a waiver of consideration by the originating agency. As such, the originating agency should consider this evidence, a medical abstract associating peripheral neuropathy with psoriasis. Accordingly, the case is REMANDED for the following action: 1. The RO or AMC should obtain all updated VA treatment records and any other outstanding records pertinent to the Veteran's claim. These records should be associated with the claims files. 2. The RO or AMC should provide the Veteran with Veterans Claims Assistance Act (VCAA) notice on his claim for secondary service connection. 3. The RO or AMC should obtain a medical opinion from a neurologist on whether the Veteran's peripheral neuropathy is due to disease or injury incurred in service, or is secondary to service-connected skin disability. The physician should review the claims files along with copies of any pertinent medical records located in the Veteran's electronic file that are not in the claims files. The medical opinion must reflect consideration of and comment on the medical abstract titled "Peripheral Neuropathy Associated with Psoriasis." The physician should render an opinion on the following: (a) Is peripheral neuropathy at least as likely as not (50 percent or greater probability) due to disease or injury incurred in service? (b) Is peripheral neuropathy at least as likely as not proximately due to service connected skin disability? (c) Is peripheral neuropathy at least as likely as not aggravated (permanently worsened) by service-connected skin disability. Aggravation is defined as a permanent worsening of the nonservice-connected disability beyond that due to the natural disease process as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. A complete rationale is required for all opinions. The physician should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). If an opinion cannot be expressed without resort to speculation, the physician should so indicate and discuss why an opinion is not possible, to include whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. See Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). 4. Then, the RO or AMC should undertake any other development it determines to be warranted. 5. After the development requested above has been completed to the extent possible, the RO should readjudicate the issue on appeal. If the benefit sought on appeal is not granted to the Veteran's satisfaction, he and his representative should be furnished a Supplemental Statement of the Case and given the requisite opportunity to respond before the claims files are returned to the Board for further appellate action. The Veteran has the right to submit additional evidence and argument on the matter or matters 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). _________________________________________________ MICHAEL LANE 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).