Citation Nr: 18139942 Decision Date: 10/01/18 Archive Date: 10/01/18 DOCKET NO. 15-36 223 DATE: October 1, 2018 REMANDED Entitlement to service connection for Parkinson’s disease, to include as due to exposure to contaminated water at Camp Lejeune, is remanded. Entitlement to service connection for stroke and residuals thereof, to include as due to Parkinson’s disease, and to include as due to exposure to contaminated water at Camp Lejeune is remanded. Entitlement to service connection for vision problems, to include as due to Parkinson’s disease and stroke, is remanded. Entitlement to service connection for left leg paralysis, to include as due to Parkinson’s disease and stroke, is remanded. Entitlement to service connection for memory loss, to include as due to Parkinson’s disease and stroke, is remanded. Entitlement to special monthly compensation (SMC) based on housebound status is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1966 to January 1967. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a March 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a Board hearing before the undersigned Veterans Law Judge in September 2017. A transcript of the proceeding is associated with the claims file. The Board finds that additional development is necessary prior to final adjudication of the claims remaining on appeal. First, with respect to the Veteran’s claim for entitlement to service connection for Parkinson’s disease, the Board finds that an additional VA examination would be of assistance. The Veteran seeks entitlement to service connection for Parkinson’s disease, to include as due to his exposure to contaminated water at Camp Lejeune during his period of service. The Board notes that Veteran was afforded a VA examination in April 2017. The VA examiner determined that the Veteran has no signs or symptoms of Parkinson’s disease. While the Board recognizes that the VA examiner supported the findings by citing to observations upon an in-person examination, the Board also notes that the record contains conflicting evidence. For instance, an October 2000 comprehensive intermediate examination report by neurologist Dr. J. Friedlander noted a diagnosis of Parkinson’s disease with mild freezing phenomenon. The report also discussed the Veteran’s medication for Parkinson’s disease treatment and indicated the Veteran’s candidacy for a trial study for a new medication to treat Parkinson’s disease. Additionally, an August 2003 examination by neurologist Dr. B. Rosenthal noted that the Veteran’s history is “consistent with Parkinson’s disease.” Dr. B. Rosenthal continued by noting that “[o]n exam, [the Veteran] has evidence of cogwheel rigidity bilaterally and his movements are somewhat bradykinetic and he appears to be in pain with joint movement. He also has some shakiness in the right hand.” Moreover, Social Security Administration (SSA) disability adjudication records further document Parkinson’s disease. SSA determined that the Veteran was disabled for SSA disability purposes due to Parkinson’s disease and carpal tunnel syndrome as of August 2008. The Veteran was afforded consultative examinations in October 2008 and November 2008, both of which rendered a diagnosis of Parkinson’s. More recently, post-service treatment records indicate that the Veteran has been taking Carbidopa for Parkinson’s disease. In an August 2017 treatment visit report, the Veteran was noted to have “Parkinsonism-type features.” See also November 2013 psychological consultation (where the Veteran was noted to have exhibited “some resting tremors in his right hand”). Of importance, the Board is cognizant that the Veteran was hospitalized for a stroke and that the Veteran’s symptoms may be attributed to stroke, and not Parkinson’s disease. Due to the conflicting evidence of record that indicates that the Veteran may have Parkinson’s disease, the Board finds that an additional VA examination is necessary to resolve the ambiguity of record. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). Next, with respect to the Veteran’s claim for entitlement to service connection for stroke, the Board notes that the Veteran alleged stroke as due to Parkinson’s disease and as due to exposure to contaminate water at Camp Lejeune. See September 2017 hearing testimony. The Board notes that the Veteran was afforded VA examinations in February 2015 and April 2017. Both examiners determined that the Veteran’s stroke was not related to service. The April 2017 examiner further determined that stroke was less likely than not proximately due to or the result of the Veteran’s claimed Parkinson’s disease because there “is [no] diagnosis of a separate [left leg condition].” The Board finds that this determination does not address whether the Veteran’s stroke was caused by or aggravated by the Veteran’s claimed Parkinson’s disease. As such, the Board finds that a VA examination is required to determine whether the Veteran’s stroke was caused by or aggravated by the Veteran’s claimed Parkinson’s disease. Additionally, the Veteran alleges that an Institute of Medicine (IOM) article stands for the proposition that contaminated water at Camp Lejeune causes stroke. See Veteran’s April 2017 correspondence; see also Veteran’s May 2017 correspondence. As it does not appear that the February 2015 VA examiner reviewed this report in determining that the Veteran’s stroke was not caused by exposure to contaminated water, the Board finds that the evidence should be evaluated by a VA examiner. See IOM report submitted August 2015 entitled Review of VA Clinical Guidance for the Health Conditions Identified by the Camp Lejeune Legislation. The VA examiner is asked to provide a nexus opinion regarding whether the Veteran’s stroke is attributed to exposure to contaminated water at Camp Lejeune, after evaluating the IOM report. As to the Veteran’s claim for entitlement to service connection for vision problems, the Board finds that remand for additional development is necessary. First, as with the Veteran’s citation to an IOM article relating stroke to contaminated water exposure, the Veteran posits the same argument regarding the causation of his vision problems. See Veteran’s April 2017 correspondence. The Board finds a VA examination is necessary to evaluate and discuss the significance of the IOM report in providing an opinion as to the nature and etiology of the Veteran’s vision problems. Second, the Board notes that the Veteran was afforded a May 2017 VA examination for his vision impairment. The examiner determined that there was no evidence of a vision problem that is at least as likely as not caused by or the result of the Veteran’s Parkinson’s disease. Additionally, the examiner determined that it is more likely than not that the Veteran’s vision problem is due to or a result of ischemic stroke. As the claim for entitlement to service connection for stroke has been remanded for additional development, the Board finds that the Veteran’s claim for entitlement to service connection for a vision problem must too be remanded for a VA examination to determine whether entitlement is warranted on a secondary basis, as due to stroke. With respect to the Veteran’s claim for entitlement to service connection for left leg paralysis, the Board finds that a VA examination is necessary to evaluate the nature and etiology of the claimed condition. The Board notes that an April 2017 VA examiner determined that there is no diagnosis of a separate left leg condition. However, there was mild left lower extremity decreased sensation found upon examination in April 2017. Additionally, the Veteran was assessed with left hemiparesthesia of the left leg in July 2017. See also Dr. J. Friedlander’s October 2000 examination report (where mild freezing phenomenon was noted); August 2017 treatment visit (where the Veteran noted he would like to explore options for treatment of left leg freezing). Based on the record’s indication that a condition exists, and the Veteran’s reports that it is attributed to Parkinson’s disease and/or stroke, the Board finds a remand is necessary to discuss entitlement to service connection on a secondary basis. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Regarding the Veteran’s claim for entitlement to service connection for memory loss, the Board finds the April 2017 VA examination inadequate, necessitating a new VA examination. The VA examiner determined there was no objective diagnosis of memory loss. Furthermore, the examiner opined to a lack of nexus and a lack of a basis for secondary service connection. Upon a review of the evidence, the Board notes that after a November 2013 psychological consultation, Dr. M. P. G. diagnosed memory problems. Additionally, an August 2017 treatment visit indicated possible memory impairment. As the evidence is conflicting with respect to this impairment, the Board finds a new VA examination is required to resolve the ambiguity as to whether the Veteran has a memory impairment. Finally, the Veteran has claimed entitlement to SMC. As the Veteran’s other pending claims must still undergo development, the Board finds that the issue of entitlement to special monthly compensation is inextricably intertwined with the issue of entitlement to service connection for Parkinson’s disease, inter alia. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are “inextricably intertwined” when a decision on one issue would have a “significant impact” on a veteran’s claim for the second issue). Accordingly, the Board must defer deciding these claims, pending the outcome of the intertwined claims. The matters are REMANDED for the following action: 1. Contact the Veteran and request that he provide information as to any outstanding records pertaining to his claimed conditions, specifically to include any outstanding private treatment records. He should be asked to authorize the release of any outstanding pertinent non-VA medical records. 2. Attempt to obtain relevant outstanding VA treatment records. 3. Schedule the Veteran for a VA examination with a neurologist to be conducted after the development requested in (1)-(2) to assess the Veteran for Parkinson’s disease based on reported symptoms. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. (a.) The examiner must take a detailed history from the Veteran. Please identify with specificity any neurodegenerative disabilities which are currently manifested, or which have been manifested at any time since August 2014, the date of the claim. If there is any clinical or medical basis for corroborating or discounting the reliability of the history provided by the Veteran, the examiner must so state, with a complete explanation in support of such a finding. (b.) The examiner should discuss whether the Veteran has symptoms consistent with Parkinson’s disease, and if so, whether the claimed symptoms are due to this disorder. If the Veteran’s claimed symptoms are not due to his alleged Parkinson’s, the examiner should discuss the etiology of symptoms, to include whether the symptoms are due to stroke. The examiner should specifically address Dr. J. Friedlander’s October 2000 examination; Dr. B. Rosenthal’s August 2003 examination; Dr. O. M. F.’s October 2008 consultative examination; Dr. J. W.’s November 2008 consultative examination; and the records indicating medicinal treatment for Parkinson’s disease. The examiner should also discuss whether the Veteran has symptoms consistent with atypical Parkinson’s disease. (c.) For each diagnosis identified in (a.) above, if any are identified, is it at least as likely as not (i.e. probability of 50 percent or greater) that the Veteran’s neurodegenerative disability was either incurred in, or is otherwise related to, the Veteran’s active duty service? The examiner should specifically address the Veteran’s exposure to contaminated water at Camp Lejeune. (d.) The examiner must provide all findings, along with a complete rationale for his or her opinion(s), in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state so and provide a rationale for this conclusion, including an explanation of whether there is any potentially available information that, if obtained, would allow for a non-speculative opinion. 4. Schedule the Veteran for a VA examination with an appropriate VA examiner to determine the nature and etiology of the Veteran’s stroke. The entire claims file, to include a complete copy of this remand must be made available to the examiner, and the report of examination should include discussion of the Veteran’s assertions. All necessary tests and studies should be accomplished (with all findings made available to the examiner prior to the completion of his/her report), and all clinical findings should be reported in detail. (a.) Without reliance on the February 2015 and April 2017 VA, the examiner should render an opinion addressing whether it at least as likely as not (i.e. probability of 50 percent or greater) that the Veteran’s stroke, to include residuals thereof, was either incurred in, or is otherwise related to, the Veteran’s active duty service? The examiner should specifically review the IOM report submitted August 2015 entitled Review of VA Clinical Guidance for the Health Conditions Identified by the Camp Lejeune Legislation to determine whether exposure to contaminated water caused his stroke. (b.) Without reliance on the February 2015 and April 2017 VA examination reports, the examiner should determine whether it is at least as likely as not that the Veteran’s cerebrovascular disability, to include residuals thereof, was caused by the Veteran’s claimed Parkinson’s disease. (c.) The VA examiner should determine whether it is at least as likely as not that the Veteran’s cerebrovascular disability, to include residuals thereof, was aggravated by the Veteran’s claimed Parkinson’s disease. 5. Schedule the Veteran for a VA examination with an appropriate VA examiner to determine the nature and etiology of the Veteran’s vision problems. The entire claims file, to include a complete copy of this remand must be made available to the examiner, and the report of examination should include discussion of the Veteran’s assertions. All necessary tests and studies should be accomplished (with all findings made available to the examiner prior to the completion of his/her report), and all clinical findings should be reported in detail (a.) The examiner should render an opinion addressing whether it at least as likely as not (i.e. probability of 50 percent or greater) that the Veteran’s vision problems, were either incurred in, or is otherwise related to, the Veteran’s active duty service? The examiner should specifically review the IOM report submitted August 2015 entitled Review of VA Clinical Guidance for the Health Conditions Identified by the Camp Lejeune Legislation to determine whether exposure to contaminated water caused his vision problems. (b.) The examiner should determine whether it is at least as likely as not that the Veteran’s vision problems were caused by either the Veteran’s claimed Parkinson’s disease or the Veteran’s stroke. (c.) The VA examiner should determine whether it is at least as likely as not that the Veteran’s vision problems were aggravated by the Veteran’s claimed Parkinson’s disease or the Veteran’s stroke. 6. Schedule the Veteran for a VA examination with an appropriate VA examiner to determine the nature and etiology of the Veteran’s alleged left leg paralysis. The entire claims file, to include a complete copy of this remand must be made available to the examiner, and the report of examination should include discussion of the Veteran’s assertions. All necessary tests and studies should be accomplished (with all findings made available to the examiner prior to the completion of his/her report), and all clinical findings should be reported in detail. (a.) The examiner must take a detailed history from the Veteran. Please identify with specificity any left leg disabilities which are currently manifested, or which have been manifested at any time since August 2014, the date of the claim. The examiner should address the July 2017 assessment of hemiparesthesia and Dr. J. Friedlander’s October 2000 report in particular. (b.) The examiner should determine whether it is at least as likely as not that the Veteran’s left leg disabilities, if any are found to exist upon examination, were caused by either the Veteran’s claimed Parkinson’s disease or the Veteran’s stroke. (c.) The VA examiner should determine whether it is at least as likely as not that the Veteran’s left leg disabilities, if any are found to exist upon examination, were aggravated by the Veteran’s claimed Parkinson’s disease or the Veteran’s stroke. 7. Schedule the Veteran for a VA examination with an appropriate VA examiner to determine the nature and etiology of the Veteran’s alleged memory loss. The entire claims file, to include a complete copy of this remand must be made available to the examiner, and the report of examination should include discussion of the Veteran’s assertions. All necessary tests and studies should be accomplished (with all findings made available to the examiner prior to the completion of his/her report), and all clinical findings should be reported in detail. (a.) The examiner must take a detailed history from the Veteran. Please identify with specificity any memory impairments which are currently manifested, or which have been manifested at any time since August 2014, the date of the claim. (b.) In particular, the examiner should address Dr. M. P. G.’s November 2013 psychological consultation and the August 2017 treatment visit indicating possibly memory impairment. (c.) The examiner should determine whether it is at least as likely as not that the Veteran’s memory impairment, if an impairment is found to exist upon examination, was caused by either the Veteran’s claimed Parkinson’s disease or the Veteran’s stroke. (d.) The VA examiner should determine whether it is at least as likely as not that the Veteran’s memory impairment, if an impairment is found to exist upon examination, was aggravated by the Veteran’s claimed Parkinson’s disease or the Veteran’s stroke. For purposes of all opinions requested above, aggravation is defined as any increase in severity that is proximately due to or the result of a service-connected disease or injury and not due to the natural progress of the disease. The determination of aggravation due to a service-connected disability or disabilities should be made independent of any additional non-service connected stressors/disabilities that may cause aggravation. The VA examiners should set forth all examination findings, along with complete rationale for all conclusions reached. In rendering all requested opinions, the VA examiners should consider all pertinent evidence, to include the pertinent medical evidence and lay statements from the Veteran. 8. Thereafter, readjudicate the issues on appeal, including entitlement to service connection for SMC. If any benefit sought remains denied, issue a Supplemental Statement of the Case to the Veteran and his representative. After allowing an appropriate amount of time for response, return the case to the Board for review. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Morrad, Associate Counsel