Citation Nr: 1800827 Decision Date: 01/05/18 Archive Date: 01/19/18 DOCKET NO. 14-15 540 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for the residuals of a traumatic head injury. 3. Entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for a back disability. 5. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to herbicide exposure. 6. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to herbicide exposure. 7. Entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as secondary to herbicide exposure. 8. Entitlement to service connection for peripheral neuropathy of the right upper extremity, to include as secondary to herbicide exposure. REPRESENTATION Veteran represented by: James M. McElfresh, II, agent WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD J. L. Prichard, Counsel INTRODUCTION The Veteran had active service from February 1968 to November 1970. He served in Vietnam as a Combat Engineer. This matter comes before the Board of Veterans' Appeals (Board) on appeal of rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran appeared at a videoconference hearing before the undersigned Veterans Law Judge in May 2015. A transcript is in the record. These appeals were previously before the Board in August 2016. The Board granted entitlement to a 70 percent rating, but no more, for PTSD, and granted service connection for tinnitus. Those appeals are final, and will not be revisited. The remaining claims for service connection were remanded for additional development, as was a claim for entitlement to service connection for ischemic heart disease and a heart murmur, to include as secondary to herbicide exposure and PTSD. Subsequently, entitlement to service connection for supraventricular arrhythmia claimed as ischemic heart disease and heart murmur was granted in a January 2017 rating decision. This is considered a complete grant of the benefits sought on appeal, and the matter is no longer before the Board. The remaining claims for service connection have been returned for further appellate review. The August 2016 Board decision also denied entitlement to TDIU. Afterwards, the Veteran submitted a new claim for TDIU in September 2016. This claim was denied in a March 2017 rating decision. The Veteran submitted a notice of disagreement in March 2017, a statement of the case was issued in April 2017, and a substantive appeal was received that same month. However, as the matter has not yet been certified to the Board, it will be the subject of a separate decision. The issues of entitlement to service connection for peripheral neuropathy of the left lower extremity, right lower extremity, left upper extremity, and right upper extremity are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The weight of the competent and probative evidence does not show a current diagnosis of hypertension. 2. The Veteran does not have a diagnosis of traumatic brain injury (TBI) or a diagnosis of any other disability related to an injury of the head during service. 3. The Veteran has a current diagnosis of hearing loss that meets VA standards, and exposure to acoustic trauma in service is conceded; however, hearing loss was not shown until many years after discharge, and the preponderance of the evidence is against a finding of a nexus between the current hearing loss and the acoustic trauma in service. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107(b) (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2017). 2. The criteria for service connection for the residuals of a traumatic head injury have not been met. U.S.C. §§ 1110, 5107(b); 38 C.F.R. § 3.303 (2017). 3. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist VA is to provide claimants with notice and assistance. The Veteran was provided with notification letters dated February 2013 and May 2014, prior to the initial adjudication of his claims in letters. Regarding the duty to notify, the Veteran has been afforded VA examinations of his claimed disabilities, and the examiners have expressed opinions pertaining to the etiology of these disabilities. The Veteran's VA treatment records have also been obtained, as have records from the Social Security Administration (SSA). He has not identified any pertinent private medical records, and the transcript of his hearing is in the claims file. As such, the Board will proceed with consideration of the Veteran's appeal. Service Connection The Veteran contends that he has developed several chronic disabilities as a result of injuries and experiences during active service. He believes that his chronic back disability is the result of his military occupational specialty of a combat engineer, which involved a great deal of physical labor. The Veteran states that he sustained an injury to his head when he was hit by a satchel charge, and he believes that his headaches are the result. He asserts that his bilateral hearing loss is the result of noise exposure during service. Finally, the Veteran says that he has developed hypertension due to service or due to his service-connected PTSD. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167(Fed. Cir. 2004); 38 C.F.R. § 3.303. If cardiovascular-renal disease to include hypertension or other organic diseases of the nervous system such as hearing loss become manifest to a degree of 10 percent within one year of separation from active service, these diseases are presumed to have been incurred during active service, even though there is no evidence of them during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. However, this method may be used only for the chronic diseases listed in 38 C.F.R. § 3.309. Walker v. Shinseki, 708 F.3d 1331, 1336-38(Fed. Cir. 2013). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 497 (1997). In relevant part, 38 U.S.C. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377(Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337(Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). Hypertension The Veteran contends that he has developed hypertension due to active service. He believes that this disability was incurred as a result of the anxiety and stress produced by his service-connected PTSD. Besides direct and presumptive service connection noted above, a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. An increase in severity of a nonservice-connected disability that is proximately due to or the result of a service connected disability may also be service connected. 38 C.F.R. § 3.310. The Veteran's service treatment records do not include findings or complaints pertaining to high blood pressure, and do not have a diagnosis of hypertension. The November 1970 discharge examination was normal, with a blood pressure reading of 124/80. 3/8/2013 STR - Medical, p. 3. His post-service medical records are also negative for a diagnosis of hypertension. There is no diagnosis of this disability dated within a year of discharge from service. Neither the private records that have been received nor the VA records list hypertension as a current diagnosis or problem. These records include many blood pressure readings, of which the vast majority are normal. The two exceptions are an April 2012 private back examination with a reading of 146/97 and a December 2013 private examination with a reading of 170/108. See 5/21/2014 Medical Treatment Records - Furnished by SSA, p. 35 and 12/21/2016 Medical Treatment Records - Furnished by SSA, p. 42. However, neither of these examinations discussed the high blood pressure, made a diagnosis of hypertension or otherwise noted a chronic problem. VA treatment records show that the Veteran denied a history of hypertension as recently as July 2013. 7/27/2014 Legacy Content Manager Documents (LCMD), Capri, p. 26. In April 2015, his attending physician noted that the Veteran's blood pressure was normal and that his blood pressure was within guidelines for age. 4/3/2017 LCMD, Capri, p. 164. A review of the Veteran's VA treatment records shows he has been afforded blood pressure screenings on a regular basis by his VA primary care providers through 2016 without any abnormal findings or diagnoses. The Veteran was afforded a VA examination for hypertension in November 2016. The examiner reviewed the Veteran's claims file and conducted an in-person examination. Initially, the examiner noted that there was no mention of hypertension in the service treatment records. Next, the examiner added that recent VA treatment records did not mention hypertension, and all of his blood pressure readings looked normal. The Veteran denied a history of diagnosis or treatment for hypertension. The Veteran stated that his blood pressure has been low. On current examination, he did not have hypertension. His blood pressure was obtained three times, with readings of 134/89, 125/88, and 127/87. The examiner concluded that there was no diagnosis of hypertension. 11/9/2016 C&P Exam, p. 1. The Board finds that the weight of the evidence is against first criterion for service connection, a diagnosis of a current disability. The Board notes that the existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. §§ 1110, 1131; see, e.g., Degmetich v. Brown, 104 F. 3d 1328(1997) (holding that section 1110 of the statute requires the existence of a present disability for VA compensation purposes). In this case, the Board finds that the weight of the competent and probative does not reflect a current diagnosis of hypertension. See McClain v. Nicholson, 21 Vet. App. 319, 321(2007). Indeed, the Board finds that competent medical evidence of record, to include the November 2016 VA examination which included a physical examination and blood pressure testing, to weigh heavily against a finding of a current disability. In doing, the Board acknowledges a January 2014 record from Central Utah Clinic that notes a diagnosis of hypertension, nos. The Board notes such in its August 2016 remand and requested additional development to obtain additional competent evidence on this matter. However, as the January 2014 record did not indicate blood pressure readings, a history from the Veteran, or provide an explanation for this diagnosis, the Board places less weight on it. In looking at the record as a whole, to include VA treatment records, SSA records, and the 2016 VA examination report, the Board finds that the preponderance of evidence weighs against a diagnosis of hypertension during or proximately to the appeal period. In the absence of competent and probative evidence to show that the Veteran has his claimed disability, service connection cannot be established as the first element is not met. As the Board finds that the evidence does not show a current diagnosis of hypertension, then secondary service, to include as due to service-connected PTSD, is not for consideration. As the preponderance of the evidence is against the claim, the Board finds that service connection for hypertension is not warranted. Residuals of a Head Trauma The Veteran contends that he sustained traumatic brain injury as a result of being exposed to satchel charges and enemy mortar fire. 4/9/2016 NOD, p. 2. His service treatment records are negative for a report of an injury to the head. They are also negative for complaints or treatment pertaining to headaches, dizziness, or any other symptoms commonly associated with a traumatic head injury. The November 1970 discharge examination was normal, with a normal head, face, neck, and scalp. 3/8/2013 STR - Medical, p. 3. The post-service medical records are also negative for a diagnosis for the residuals of head trauma or TBI. On a March 2013 VA mental health outpatient note, the Veteran denied a history of head trauma, TBI, and loss of consciousness. 3/26/2014 LCMD, Capri p. 7. Subsequent mental health notes and VA PTSD examinations uniformly state that the Veteran does not have a diagnosis of TBI. A January 2014 private examination received from SSA did not include the residuals of TBI, or headaches or other related symptoms among the Veteran's disabilities. 12/21/2016 Medical Treatment Records - Furnished by SSA, p. 143. VA treatment records include a February 2015 primary care note that shows the Veteran complained of headaches and neck pain. This had begun about six months earlier and occurred daily. 3/3/2017 Capri, p. 207. In August 2015, the Veteran underwent a VA neurology consult due to his headaches. He reported that the headaches began about a year ago. There was no trauma, injury, or event the Veteran could point to as a cause. The pain came from the back of the neck/head on the left and moved to the top of the head. On examination, there was tenderness in the left occipital groove that reproduced his symptoms. The staff neurologist also reviewed prior studies, to include a June 2015 CT of the head, a September 2014 MRI of the spine, and lab results from February 2015. After taking a history, examining the Veteran, and reviewing diagnostic studies, the neurologist's impression was left sided occipital neuralgia. 3/3/2017 Capri, pp. 194-195. The Veteran received a left sided occipital nerve block in October 2015. 3/3/2017 Capri, p. 189. January 2016 records show that the Veteran was seen for chronic headaches of three weeks duration. He reported having a December 2015 injection in his neck for headaches, but they returned even worse after two weeks. The Veteran provided a positive response for severe headaches, but he denied many other symptoms, to include difficultly speaking/walking/with balance, seizures, or syncope. 3/3/2017 Capri, p. 180. The Veteran had a VA examination for the initial evaluation of the residuals of TBI in October 2016. The examination was conducted by a Board Certified neurologist. The Veteran described an enemy soldier throwing a satchel charge at the bulldozer he was driving. He jumped from the cab and lost consciousness. Afterwards, he resumed his usual duties, and did not receive any significant medical care. On examination, the Veteran reported having chronic headaches that had recently worsened. He had obstructive sleep apnea, which was noted to cause headaches. The Veteran was reported to have told an August 2015 VA examiner that he started having headaches about a year ago. There had been no trauma or injury event the Veteran could identify. There were no clinically significant findings of seizures, dizziness, hypersensitivity, vision problems, cranial nerve dysfunction, decreased sense of taste or smell; hearing loss; tinnitus; speech or swallowing difficulties; weakness or paralysis; numbness or paresthesias or sensory change; relevant pain; bladder problems; bowel problems; erectile dysfunction; difficulty walking; balance or coordination problem; fatigue; malaise; autonomic dysfunction; endocrine dysfunction; cognitive deficits; psychiatric symptoms; or neurobehavioral impairment. He was noted to be service connected for PTSD and had symptoms related to that disability. However, the neurologic examination showed no significant cognitive deficits and was nonfocal. The examination report reflects that the Veteran did not have any subjective symptoms or any mental, physical or neurological conditions or residuals attributable to a TBI. The examiner summarized by concluding that the Veteran did not have a current disability of TBI from service. As there was no diagnosis, the examiner did not provide any additional opinions. 10/17/2016 C&P Exam, p. 1. Initially, the Board notes that it accepts the Veteran's description of the incident with the satchel charge during service. Although the medical records show that the Veteran initially denied a history of head injury when his headaches began, it is conceivable that he did not first think to link the incident in service to his current headaches. As such, the Board finds this in-service event to be consistent with the Veteran's military history, to include military occupational specialty. However, the Board finds that the weight of the evidence is against a finding in favor of service connection for the residuals of a head trauma. There is no probative competent medical evidence that the Veteran has any residual disability that has been attributed to a head injury. The Veteran's private and VA treatment records are negative for a head injury, and his records repeatedly indicate that he denied a history of TBI. The October 2016 examiner considered the Veteran's contentions regarding the satchel charge. However, this examiner reviewed the Veteran's current symptoms and concluded that they are not consistent with TBI. This is consistent with the finding of the August 2015 neurology consult, which instead of a diagnosis of TBI reached an impression of left sided occipital neuralgia. The Board also notes that the August 2015 consult and October 2016 VA examination were conducted by neurologist. The Board finds that a review by such a specialist is important and lends greater weight to these pieces of evidence. As the Veteran does not have a current diagnosis of TBI or any other residual disability due to a head trauma, the first element of service connection is not met and his claim must be denied. The Board has considered the many medical texts submitted in support of the Veteran's claim by his representative. While informative, those texts which discuss the general etiology of TBI are no substitute for an actual examination by a neurologist. As such medical literature is not specific to the facts and history of this Veteran, the Board places little if any weight on these pieces of evidence. The 2015 VA consult and 2016 VA examination reports outweigh these medical texts and they reflect that the Veteran not have residuals of an in-service event related to a TBI. The Board has also considered entitlement to service connection for the Veteran's migraine headaches aside from being a residual to head trauma. However, although the Veteran does have a well-established current diagnosis of migraine headaches, the service records do not reflect evidence of headaches during service. The competent and probative evidence of record establishes that this disability first began from 2014 to 2015, and there is no evidence of a nexus between the current headaches and service. The Board recognizes the Veteran's sincere belief that his headaches are due to service. However, while he is competent to describe his headaches, he does not report that they have existed ever since service. The Veteran does not have any medical training, and is not competent to express an opinion as to the etiology of his headaches, as these involve complex neurological functions. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462-63 (2007). In fact, the only opinion he has expressed is to relate them to the satchel charge incident in service, and a residual disability due to head trauma was not found by the October 2016 examiner. As there is no evidence of headaches in service and no competent opinion that relates the current headaches to service, service connection is not established. Bilateral Hearing Loss The Veteran contends that his hearing loss is the result of the loud noises to which he was exposed during service. The Board finds that the competent and credible evidence establishes that he was exposed to acoustic traumas during service as consistent with the circumstances and places of his active service as a combat engineer in Vietnam. Entitlement to service connection for impaired hearing is subject to the additional requirements of 38 C.F.R. § 3.385, which provides that service connection for impaired hearing shall not be established when hearing status meets pure tone and speech recognition criteria. Hearing status will be considered a disability for the purposes of service connection when the auditory thresholds in any of the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz is 40 decibels or greater; the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The United States Court of Veterans Appeals (Court) has indicated that the threshold for normal hearing is between 0 and 20 decibels and that higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155 (1993). The Veteran's service treatment records show that his hearing was normal upon entering service. These records are negative for complaints of hearing loss. The Veteran was afforded a hearing test as part of his November 1970 separation examination. The results show normal hearing under both ASA and ISO-ANSI standards. 3/8/2013 STR - Medical, p. 3. Post-service records show that the Veteran was afforded a VA hearing loss examination in April 2013. The claims file was reviewed by the examiner. The Veteran indicated his hearing loss began two or three years ago, which was approximately 40 years after release from service. Testing revealed that the Veteran has hearing loss that meets the standards of 38 C.F.R. § 3.385. However, the examiner opined that it was less likely than not that this hearing loss was caused by or a result of an event in military service. She explained that the Veteran had normal hearing at discharge with no significant decrease from the entrance examination. Given the normal hearing at discharge, it was less likely than not the current hearing loss was caused by or a result of his military noise exposure. 6/12/13 C&P Exam, p. 1. As explained in the 2016 remand, the Board found that the opinion ran afoul of legal precedent and remand to obtain another opinion. At the May 2015 Board hearing, the Veteran testified that he was exposed to all types of excessive noise. This included noise from heavy construction equipment, helicopters and weapons, and it was loud enough to produce ringing in his ears. He was not issued any hearing protection. 5/13/2015 Hearing Testimony, pp. 6-11. In September 2016, an addendum opinion was obtained from the April 2013 examiner. Once again she reviewed the Veteran's claims file. The examiner continued to believe it was less likely than not that the Veteran's hearing loss was caused by or a result of his military noise exposure, and continued to note the normal hearing at the separation examination with no significant decrease from the entrance examination. In addition, the examiner conducted a literature review and cited findings regarding noise and military service from the Institute of Medicine (IOM) to support her opinion. These studies indicate that the most pronounced effects of a given noise exposure are measurable immediately following the exposure. On the other hand, there was not sufficient evidence from longitudinal studies in animals or humans to determine whether permanent noise-induced hearing loss can develop much later in one's lifetime long after cessation of that noise exposure. After quoting from the IOM report, the VA audiologist explained that this study indicates that based on what we know about anatomy and physiology it is unlikely that a delayed onset of hearing loss occurs. The audiologist added that preliminary research has been done since the IOM study indicating there are likely subclinical changes in the auditory system as a result of noise exposure, even in the absence of permanent threshold shifts. The changes in the auditory system are not necessarily linked to actual changes in auditory thresholds as measured on an audiogram. The actual, measurable long-term effects of these changes in the auditory system are still unknown. As it is unknown what the long-term effects of the changes in the auditory system might be, it would be injudicious to assert that these studies indicate a delayed onset of noise-induced hearing loss. Until further research is done to assess the effects of these neural changes, the VA audiologist stated that they "must still concur with the Institute of Medicine that based on anatomy and physiology, it is unlikely that a delayed-onset of hearing loss occurs." As such, the audiologist concurred with the previous opinion that it is less likely as not that the Veteran's hearing loss was caused by or a result of his military noise exposure. The Board finds that entitlement to service connection for bilateral hearing loss is not warranted. The evidence establishes that the Veteran has a current diagnosis of bilateral hearing loss, and his exposure to noise in service is established. However, there must also be competent evidence of a nexus between the current diagnosis and the noise exposure before service connection can be established, and this has not been shown. The April 2013 VA examiner opined it was less likely than not that the Veteran's hearing loss was related to noise exposure in service. She based her opinion on the Veteran's normal hearing at discharge from service that had no significant change since entering service, and the Veteran's report that his hearing loss had begun two or three years earlier. In her September 2016 addendum, she cited studies indicating it is unlikely that hearing loss can develop much later in one's life long after the noise exposure in question. The Board places much weight on the 2013 examination with the 2016 addendum as the audiologist noted the relevant facts, to include the Veteran's in-service and post service noise exposure, and provide an opinion with several reasons why his current hearing loss was not related to his active service. The only opinion to the contrary is the Veteran's, who relates his hearing loss to the acoustic traumas in service. However, although the Veteran is competent to describe his hearing loss, there is no evidence that the Veteran has the requisite training necessary to provide a competent opinion as to the etiology of his hearing loss. As the only competent opinion weighs against a finding of a nexus, the final criterion for service connection has not been met. The Board also finds that continuity of symptomatology has not been demonstrated. When asked at the hearing if he had experienced hearing loss or ringing in the ears during service, the Veteran replied he had experienced ringing in the ears. He did not state that he had hearing loss prior to discharge. Furthermore, he told the April 2013 examiner that his hearing loss had begun two or three years earlier. There are no medical records showing complaints or treatment for hearing loss prior to that time. The Board finds that this competent and probative evidence weight against a finding of continuity from service. Finally, the Board has also considered entitlement to service connection on a presumptive basis. However, the service treatment records do not contain any evidence of hearing loss, and the Veteran's hearing was normal at discharge. There is no evidence that the Veteran was diagnosed with hearing loss as defined by 38 C.F.R. § 3.385 within a year of discharge. Therefore, service connection cannot be presumed. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In sum, the Board finds that the preponderance of the evidence weighs against a nexus and service for bilateral hearing loss is denied. ORDER Service connection for hypertension, to include as secondary to post-traumatic stress disorder is denied. Service connection for the residuals of a traumatic head injury is denied. Service connection for bilateral hearing loss is denied. REMAND The Veteran was afforded a VA examination of his back in November 2016. He told the examiner that he began to see a chiropractor shortly after discharge that treated him for his back problems for many years. A review of the claims file shows that the Veteran had not previously reported this treatment. The records of this treatment have never been submitted, and no attempt to obtain them has ever been made. Given that the VA examiner commented negatively regarding the lack of medical evidence to support a back pathology until 1992, an attempt to obtain these records should be made. Furthermore, although the November 2016 VA examiner includes a history and comments that strongly indicates he does not believe there is a nexus between the Veteran's current back disability and active service, he never explicitly provided the requested opinion as to whether or not the current disability is related to service. The Board concludes that the examination report should be returned for an addendum that addresses this deficiency. Turning to the Veteran's claims for service connection for peripheral neuropathy in all four extremities, he was afforded a VA examination in November 2016 which found that he does not have peripheral neuropathy. Instead, the examiner opined that the Veteran has radiculopathic pain involving the C5-8 nerve roots that affects both arms, and radiculopathic pain involving the L5 and S1 nerve roots that affects both legs. 11/9/2016 C&P Exam, p. 1. However, in February 2017 the Veteran's representative submitted the report of a January 2017 examination. The Veteran told the examiner that he had experienced neuropathy in his hands and feet ever since returning from service. His previous back surgeries were noted. At the conclusion of an examination of the Veteran's feet, the impression was painful peripheral neuropathy. The examiner did not clearly indicate if this impression was for both the hands and the feet, and he explained to the Veteran that some of the peripheral neuropathy may be due to his back surgeries. He did not provide any other etiology for this disability or relate them to the Veteran's active service. 2/28/2017 Medical Treatment Record - Government Facility, p. 2. The Board observes that the January 2017 examination was conducted by a podiatrist, and not a medical doctor (MD). Nevertheless, it raises the possibility that the Veteran may have developed a diagnosis of peripheral neuropathy since the November 2016 examination. The Board finds that the Veteran must be scheduled for a new examination by a neurologist in order to confirm this diagnosis. If confirmed, the neurologist should provide an opinion regarding the etiology of this disability. Accordingly, the case is REMANDED for the following actions: 1. Contact the Veteran and ask him to provide the records from the chiropractor he states treated him for his back disability shortly after his discharge from service, as well as any other private treatment he received for his back following discharge. Inform the Veteran that in the alternative, VA will attempt to obtain these records on his behalf if he provides permission/authorization. The Veteran should also be informed that it is ultimately his responsibility to ensure these records are received by VA if he wishes to have then considered. The efforts to obtain these records should continue appropriately until they are received or it is confirmed that they likely do not exist or are not obtainable, and the Veteran should be informed if VA is unable to obtain the records on his behalf. Any records that are received should be associated with the claims file. 2. After the records requested above have either been received or confirmed to be unavailable, return the report of the November 2016 back examination to the examiner. After another review of the claims file, the examination report, and the discussion therein, the examiner must clearly state for the record whether it is as likely as not that the Veteran's current back disability was incurred in or due to active service. The reasons for all opinions should be provided. If the examiner is unable to provide an opinion without resorting to speculation, the examiner should state whether the inability is due to the limits of the examiner's knowledge, the limits of medical knowledge in general, or there is additional evidence that, if obtained, would permit the opinion to be provided. If the November 2016 examiner is not available, the claims file and examination report should be forwarded to another equally qualified examiner in order to obtain the requested opinion. A new physical examination is not required unless deemed necessary by the examiner. 3. Scheduled for a VA neurology examination in order to determine whether or not the Veteran has a diagnosis of peripheral neuropathy or any other neurological disorder in his lower and/or upper extremities. The claims file must be provided to the examiner and the examination report must indicate it has been reviewed. All indicated tests and studies should be conducted. At the conclusion of the examination and file review, the examiner should express the following opinions: a) Does the Veteran have a diagnosis of peripheral neuropathy and/or another neurological disorder in one or more of his extremities? Please identify each extremity, as appropriate. b) If the Veteran is determined to have peripheral neuropathy, is it as likely as not that peripheral neuropathy of the right lower extremity, left lower extremity, right upper extremity, or left upper extremity was incurred in or due to active service? This should include herbicide exposure during active service. c) For any other neurological diagnoses of the right lower extremity, left lower extremity, right upper extremity, or left upper extremity, was that disability incurred in or due to active service? For any disability not incurred in or due to service, the likely etiology should be provided for each extremity. In particular, the examiner should address whether or not any diagnosis is due to the Veteran's back disability or neck disability. The reasons for all opinions should be provided. The examiner's attention is directed to the report of the January 2017 examination by the Veteran's podiatrist. If the examiner finds that the Veteran does not currently have peripheral neuropathy, the examiner should state whether the January 2017 diagnosis was in error or if the peripheral neuropathy resolved. In regards to herbicide exposure, the opinion should not be limited to whether or not any peripheral neuropathy manifested within the presumptive period, but must also address service connection on a direct basis for each extremity. If the examiner is unable to provide an opinion without resorting to speculation, the examiner should state whether the inability is due to the limits of the examiner's knowledge, the limits of medical knowledge in general, or there is additional evidence that, if obtained, would permit the opinion to be provided. 4. If any benefit sought on appeal remains denied, issue a supplemental statement of the case. Then return the case to the Board, if otherwise in order The Veteran has the right to submit additional evidence and argument on the 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 2014). ______________________________________________ Paul Sorisio Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs