Citation Nr: 1802234 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 14-10 305 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUE Entitlement to service connection for left leg numbness. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD Mike A. Sobiecki, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from September 1986 to September 2012. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York. The appeal is REMANDED to the agency of original jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND The Veteran seeks service connection for left leg numbness. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110 (2014); 38 C.F.R. § 3.303 (2017). Service connection may also be granted for a disability that is proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310. His August 2012 separation examination notes "Back pain [with] numbness to left leg." The examiner's notes on the Report of Medical History completed in conjunction with the separation examination show that the Veteran had numbness/tingling to the left leg/foot for 6 years and he has recently had an increase in low back pain on the left. In April 2013, the Veteran underwent a general medical VA examination; a Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire (DBQ) was completed in conjunction with the examination. The DBQ showed no sensory deficits in the left lower extremity and no radiculopathy. The April 2013 VA examiner was subsequently asked to provide an addendum opinion to address whether the Veteran has a disability related to his claim of service connection for left leg numbness. In May 2013, the VA examiner authored this opinion. The examiner explained: "Back DBQ was done and radiculopathy was addressed in that exam. Veteran did not complain of left leg numbness (radiculopathy of the left leg) during that interview. All answers were negative for radiculopathy. Veteran does not need to be called back for an exam." In an August 2013 VA Form 21-4138, the Veteran explained that there must have been a misunderstanding or miscommunication between himself and the VA examiner. He wrote that he does suffer from numbness through his left hip and down his left leg, which could possibly be secondary to his service-connected thoracolumbar scoliosis with osteoarthritis. The Veteran requested that he be scheduled for another VA examination. In a March 2014 VA Form 9, the Veteran wrote that it would be reasonable to think his left leg numbness may be secondary to his service-connected back or hip disabilities, and requested that he be scheduled for another VA examination. Upon review of all of the evidence of record, the Board agrees with the Veteran insofar as that he should be scheduled for a new VA examination. The evidence clearly shows he suffered from left leg numbness at separation from service, and the medical examiner at that time related the condition to his back disability. The Veteran underwent a VA examination in April 2013 and an addendum opinion was authored by the same VA examiner the following month; considered together, they do not adequately address whether there exists a current disability related to the left leg numbness. Given the explanation in the addendum opinion, it appears the examiner's determination was made based solely on a lack of complaints of left leg numbness during the interview portion of the examination, and limited to no consideration was given to the service records or other lay statements of the Veteran contained in the record. Accordingly, on remand, the Veteran should be scheduled for a new VA examination to consider the nature and etiology of this condition. 38 C.F.R. § 4.2. Accordingly, the case is REMANDED for the following actions: 1. Obtain and associate with the claims file any outstanding VA treatment records. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of his left leg numbness. The examination should be performed by a physician. The examiner must review the entire claims file, to include a copy of this REMAND, in conjunction with the examination. The examiner is asked to provide responses to the following: (A) The Veteran complains of left leg numbness. Does he have a current disability associated with this complaint? All requisite testing should be performed. The Veteran's service records and lay statements should be considered. If a current disability is ruled out, a complete explanation should be provided. (B) Is it at least as likely as not (a 50 percent or greater probability) that the current disability was incurred in, or is otherwise related to, his active service? (C) Is it at least as likely as not that the current disability was proximately caused or aggravated by his service-connected thoracic scoliosis with osteoarthritis and/or left hip osteoarthritis? Question (C) requires two separate opinions: one for proximate causation and another for aggravation. The term "aggravation" means a permanent worsening of a disability beyond its natural progression. If aggravation is found, then, to the extent possible, the examiner should attempt to establish a baseline level of severity of the disability prior to its aggravation by thoracic scoliosis with osteoarthritis and/or left hip osteoarthritis. A complete rationale must be provided for all opinions expressed. The rationale should discuss the pertinent evidence of record, to include the Veteran's lay statements. The Veteran 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 remanded by the Board 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. §§ 5109B, 7112. _________________________________________________ D. JOHNSON Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252, only a decision of the Board s 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).