Citation Nr: 18145140 Decision Date: 10/30/18 Archive Date: 10/26/18 DOCKET NO. 16-34 142 DATE: October 30, 2018 REMANDED 1. Entitlement to service connection for right upper extremity carpal tunnel syndrome, to include as secondary to service-connected right wrist tendonitis, is remanded. 2. Entitlement to service connection for a heart condition (claimed as chest pain) is remanded. 3. Entitlement to a compensable initial disability rating for erectile dysfunction. REASONS FOR REMAND The Veteran had active service from August 1979 to June 1992. 1. Entitlement to service connection for right upper extremity carpal tunnel syndrome, to include as secondary to service-connected right wrist tendonitis, is remanded. After a thorough review of the claims file, the Board has determined that additional evidentiary development is necessary prior to the adjudication of the Veteran’s claim of entitlement to service connection for right upper extremity carpal tunnel syndrome, to include as secondary to service-connected right wrist tendonitis. Upon remand, the RO must obtain an adequate addendum opinion which properly considers whether the Veteran’s right upper extremity carpal tunnel syndrome is proximately due to, the result of, or aggravated by his service-connected right wrist tendonitis. VA’s duty to assist includes obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C. § 5103A(d) (2012). Furthermore, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Upon VA examination in January 2013, the VA examiner opined that the Veteran’s right carpal tunnel syndrome was less likely than not due to the Veteran’s wrist injury during active service because there was no in-service record of carpal tunnel syndrome. Notably, the same examiner opined that the Veteran’s right wrist tendonitis was at least as likely as not related to his in-service wrist injury, which ultimately resulted in a grant of service connection for right wrist tendonitis within a March 2013 rating decision. The March 2013 rating decision deferred adjudication of the Veteran’s claim of entitlement to service connection for right carpal tunnel syndrome pending an additional VA opinion as to whether the Veteran’s right carpal tunnel syndrome was caused by, related to, or aggravated by his service-connected right wrist tendonitis. Thereafter, in April 2013, a different VA examiner opined that the Veteran’s right carpal tunnel syndrome was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As a rationale, the examiner noted that the Veteran’s service treatment records were silent for carpal tunnel syndrome, that his service-connected right wrist tendonitis matched his in-service complaints of wrist pain, and he was not diagnosed with carpal tunnel syndrome in the years after service. Notably, the April 2013 opinion is inadequate to adjudicate the Veteran’s claim, because the opinion provided only addresses a theory of direct service connection, rather than the opinion that was sought by the RO in its March 2013 deferred rating decision regarding the Veteran’s claim that his current right carpal tunnel syndrome is secondary to his service-connected right wrist tendonitis. Therefore, upon remand, an adequate VA medical opinion must be obtained which fully addresses whether the Veteran’s right carpal tunnel syndrome is caused by, related to, or aggravated by his service-connected right wrist tendonitis. See Barr, 21 Vet. App. at 312. Additionally, the Board is mindful that the Veteran has also submitted a February 2018 private nexus opinion in support of his claim. Therein, a private physician (who diagnosed his carpal tunnel syndrome following an April 2012 electromyography/nerve conduction (EMG/NCV) study) opined that the Veteran’s in-service tendon injuries of both arms progressed over time to bilateral carpal tunnel syndrome. While unsupported by an adequate rationale, and thus insufficient to warrant a grant of service connection by itself, the February 2018 private nexus opinion is nevertheless probative evidence which must also be considered by the VA medical opinion obtained upon remand. 2. Entitlement to service connection for a heart condition (claimed as chest pain) is remanded. The Veteran filed a claim for entitlement to service connection for chest pain in November 2000 that was denied in a January 2002 rating decision. The Veteran properly perfected an appeal regarding his claim of entitlement to service connection for chest pain related to a severe heart condition with his submission of a timely VA Form 9 substantive appeal in October 2002, following the issuance of a May 2002 statement of the case (SOC). On the VA Form 9 the Veteran described the issue as “anterior mid and distal ischemia (myocardial images)” and as a “chronic heart condition.” The Board finds that all these documents refer to the same claimed disability and recharacterizes it as a heart condition (claimed as chest pain) to afford the Veteran the most favorable interpretation. Brokowski v. Shinseki, 23 Vet. App. 79, 85 (2009); Ingram v. Nicholson, 21 Vet. App. 232, 256-57 (2007). Although the issue has not been administratively certified to the Board, there is no indication that the appeal has been withdrawn; therefore, the Board will accept jurisdiction of this issue. Upon VA examination in January 2001, the Veteran reported chest discomfort since 1993, with fatigue, dizziness, and intermittent severe pain. Following a physical examination, the examiner diagnosed costochondritis causing chest discomfort; however, the examiner did not provide a nexus opinion as to whether there was a relationship between the Veteran’s reported chest pain and his active service, including a June 1987 in-service complaint of chest wall pain. As noted above, when VA undertakes to provide a claimant with an examination, that examination must be adequate. See Barr, supra. As the January 2001 examination did not include a nexus opinion, it is inadequate for the purposes of this appeal. Therefore, a new VA examination is necessary on remand and should include a nexus opinion. 3. Entitlement to a compensable initial disability rating for erectile dysfunction is remanded. A February 2010 rating decision granted the Veteran’s claim of entitlement to service connection for erectile dysfunction, rated as noncompensable effective June 22, 2009. Later that same month, the Veteran submitted a notice of disagreement (NOD) regarding the noncompensable initial disability rating assigned for his erectile dysfunction. Notably, an SOC has not been issued regarding the claim of entitlement to a compensable initial disability rating for erectile dysfunction. As such, the issue has been added to the appeal for the purposes of remand in order to issue an SOC. See Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). The matters are REMANDED for the following action: 1. Obtain an addendum opinion from a qualified VA examiner regarding the Veteran’s claim of entitlement to service connection for right carpal tunnel syndrome, to include as secondary to service-connected right wrist tendonitis. The Veteran’s entire claims file and a copy of this remand should be made available to and reviewed by the examiner in conjunction with the opinion. All indicated studies should be conducted, including a full and current VA examination if deemed necessary by the examiner, and all findings should be reported in detail. A clear supporting rationale is required for any opinion provided. Specifically, the examiner must offer an opinion as to the following: (a) whether it is as likely as not (a 50 percent probability or greater) that the Veteran’s right carpal tunnel syndrome is caused by his service-connected right wrist tendonitis. (b) whether it is as likely as not (a 50 percent probability or greater) that the Veteran’s right carpal tunnel syndrome is aggravated (worsened beyond its natural progression) by his service-connected right wrist tendonitis. (c) If the examiner finds that the service-connected right wrist tendonitis aggravates the Veteran’s right carpal tunnel syndrome, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the right carpal tunnel syndrome prior to aggravation. If the examiner is unable to establish a baseline for the right carpal tunnel syndrome prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. In providing the requested opinions, the examiner must include a clear discussion of all relevant lay and medical evidence of record, including, but not limited to the February 2018 private nexus opinion. 2. Schedule the Veteran for a VA examination with a qualified VA examiner regarding his claim of entitlement to service connection for a heart condition (claimed as chest pain). The Veteran’s entire claims file and a copy of this remand should be made available to and reviewed by the examiner in conjunction with the opinion. All indicated studies should be conducted and all findings should be reported in detail. A clear supporting rationale is required for any opinion provided. Specifically, the examiner must offer an opinion as to whether it is as likely as not (a 50 percent probability or greater) that any heart condition diagnosed at any time since November 2000 is etiologically related to his active service. In providing the requested opinion, the examiner must include a clear discussion of all relevant lay and medical evidence of record, including, but not limited to the Veteran’s June 1987 in-service complaint of chest wall pain. (Continued on the next page)   3. Provide the Veteran and his representative with an SOC that addresses the issue of entitlement to a compensable initial disability rating for erectile dysfunction. If the Veteran thereafter perfects a substantive appeal by submitting a timely VA Form 9, the issue should then be returned to the Board for further appellate consideration. LAURA E. COLLINS Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Chad Johnson, Counsel