Citation Nr: 18144144 Decision Date: 10/24/18 Archive Date: 10/23/18 DOCKET NO. 14-28 633A DATE: October 24, 2018 REMANDED Entitlement to service connection for peripheral neuropathy of the left upper extremity is remanded. Entitlement to service connection for peripheral neuropathy of the right upper extremity is remanded. Entitlement to service connection for peripheral neuropathy of the left lower extremity is remanded. Entitlement to service connection for peripheral neuropathy of the right lower extremity is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1983 to August 1991. The Veteran seeks entitlement to service connection for peripheral neuropathy of the left upper extremity, right upper extremity, left lower extremity, and right lower extremity. Unfortunately, the Board finds that additional development must be undertaken before these claims can be adjudicated on the merits. Service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War. For disability due to undiagnosed illness and medically unexplained chronic multisymptom illness, the disability must have been manifest either during active military service in the Southwest Asia Theater of operations or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117 (West 2014); 38 C.F.R. § 3.317(a)(1) (2017). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multisymptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A 1117(d) warrants a presumption of service connection. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C. § 1117; 38 C.F.R. § 3.317, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. at 8-9. Further, lay persons are competent to report objective signs of illness. Id. "Objective indications of chronic disability" include both signs, in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include neurologic signs or symptoms as well as neuropsychological signs or symptoms. 38 C.F.R. § 3.317(b). Here, the Veteran served aboard the USS Abraham Lincoln (CVN 72) and received the Southwest Asia Service Medal. The Board notes that the USS Abraham Lincoln (CVN 72) passed through the Strait of Hormuz into the Persian Gulf in July 1991. A review of the Veteran’s service treatment records shows that he was still onboard the USS Abraham Lincoln (CVN 72) at the time of his August 1, 1991, separation examination. As such, the record demonstrates that the Veteran had service in the Southwest Asia theater of operations during the Persian Gulf War. The Veteran’s post-service records reflect that in October 2008 the Veteran complained of pain in his shoulder radiating down his right arm, although he denied any inciting incident for this pain. He further described some occasional numbness in his bilateral hands. In approximately June 2010, the Veteran injured his right leg in a motorcycle accident and was prescribed acetaminophen / hydrocodone for leg pain. He was also prescribed gabapentin to help control chronic nerve pain in 2010. However, electrocardiogram (EKG) conducted in October 2010 indicated that the Veteran’s upper and lower extremities were within normal limits neurologically. An August 2013 VA treatment note indicated the presence of pain from the bilateral shoulders upon Hawkins–Kennedy testing, although the examination was otherwise negative, with no evidence of synovitis. To date, the Veteran has not been provided with a VA examination to determine whether his neurological symptoms of the extremities are attributable to a medically unexplained chronic multisymptom illness, i.e., a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 C.F.R. § 3.317(a)(2)(i)(B). In light of the Veteran’s service in the Southwest Asia theater of operations and subsequent treatment for neurological symptomatology, a medical opinion should be obtained which specifically considers whether the Veteran’s neurological symptoms of the extremities are due to a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, or is an individual pathology which is not traceable to active duty service. The matters are REMANDED for the following action: 1. Provide the Veteran with an appropriate VA examination by a qualified medical professional which addresses the etiology of his neurological symptomatology of the extremities. The claims file must be provided to and reviewed by the examiner in conjunction with the examination. The examiner is requested to review all pertinent records associated with the claims file. Thereafter, the examiner should address the following: (a) The examiner is asked to opine as to whether the Veteran currently has, or has had during any portion of the time period on appeal, a neurological disability of the right or left upper extremity and/or right or left lower extremity. (b) If the examiner finds that the Veteran does not meet the diagnostic criteria for a neurological disability of an extremity, then the examiner must detail which criteria were and were not met, and why. (c) If the Veteran does not have a diagnosed neurological disability of the extremities, then the examiner is asked to opine as to whether he has a qualifying chronic disability of the left and/or right upper extremity, and/or of the left and/or right lower extremity, manifested by neurologic and/or neuropsychological signs or symptoms, to include as part of a multi-symptom illness, as defined in 38 C.F.R. § 3.317(a)(2)(i) (2017). (d) If the Veteran is not diagnosed with a neurological disability of the extremities, or a qualifying chronic disability, but his symptoms are attributed to another diagnosis, not already service-connected, then the examiner is asked to opine as to whether it is at least as likely as not (50 percent probability or greater) that the diagnosed disability began in service, was caused by service, or is otherwise related to the Veteran’s military service, to include service in the Persian Gulf. In rendering the above requested opinions, the examiner should address the lay statements of record concerning his symptoms since returning from the Persian Gulf. 2. Thereafter, consider all of the evidence of record and readjudicate the service connection claims on appeal. If any benefit sought is not granted, then issue a Supplemental Statement of the Case and allow the Veteran and his representative an opportunity to respond. U. R. POWELL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Anthony M. Flamini, Counsel