Citation Nr: 18159270 Decision Date: 12/18/18 Archive Date: 12/18/18 DOCKET NO. 15-07 277 DATE: December 18, 2018 REMANDED Entitlement to service connection for arthritis is remanded. Entitlement to a rating in excess of 10 percent for residuals of left wrist disability (left wrist disability) is remanded. Entitlement to a rating in excess of 10 percent for carpal tunnel syndrome of the left upper extremity is remanded. Entitlement to compensation pursuant to 38 U.S.C. § 1151 for diabetes mellitus claimed as the result of VA treatment is remanded. Entitlement to compensation pursuant to 38 U.S.C. § 1151 for residuals of a stroke, claimed as the result of VA treatment is remanded. Entitlement to compensation pursuant to 38 U.S.C. § 1151 for a heart disability claimed as the result of VA treatment, to include prescribed medication is remanded. Entitlement to compensation pursuant to 38 U.S.C. § 1151 for an eye disability claimed as the result of VA treatment is remanded. Entitlement to compensation pursuant to 38 U.S.C. §1151 for a headache disability claimed as the result of VA treatment, to include prescribed medication, is remanded. Entitlement to compensation pursuant to 38 U.S.C. § 1151 for a subdural hematoma claimed as the result of VA treatment, to include prescribed medication, is remanded. REASONS FOR REMAND The Board finds that additional development is necessary before a decision may be rendered regarding the issues on appeal. Initially, the Board notes that the Veteran submitted additional evidence pertaining to his 1151 claims and during the March 2018 Board hearing, he indicated that he did not waive agency of original jurisdiction (AOJ) review of this new evidence. The Board may not consider additional evidence not previously reviewed by the AOJ, unless a waiver of initial AOJ review is obtained from the Veteran. Disabled American Veterans, et. al. v. Secretary of Veterans Affairs, 327 F. 3d 1339 (Fed. Cir. 2003); 38 C.F.R. § 20.1304 (c). Since the Veteran does not want to waive AOJ review, and the AOJ has not issued a supplemental statement of the case (SSOC) which considers the new evidence, a remand is necessary. Additionally, the evidence shows that the Veteran receives Social Security Administration (SSA) benefits; however, SSA records have not been associated with the claims file. Further, the Veteran provided private medical records which appear to be incomplete. Therefore, these SSA and private medical records should be obtained on remand. 1. Entitlement to service connection for arthritis is remanded. The Veteran contends that he has rheumatoid arthritis, to include carpal tunnel syndrome in his right wrist, back, thumbs and feet, due to his left wrist disability. The medical evidence shows treatments for arthritis; however, a medical opinion has not been obtained regarding the etiology of his arthritis. Therefore, upon remand, one should be obtained. 2. Entitlement to ar rating in excess of 10 percent for residuals of left wrist disability (left wrist disability) is remanded. 3. Entitlement to a rating in excess of 10 percent for carpal tunnel syndrome of the left upper extremity is remanded. During the March 2018 Board hearing, the Veteran reported that his left wrist disabilities have worsened since they were evaluated in 2015. Therefore, a remand is necessary to afford the Veteran to determine the current severity of his left wrist disabilities. 4. Entitlement to compensation pursuant to 38 U.S.C. § 1151 for an eye disability claimed as the result of VA treatment is remanded. The Veteran seeks VA compensation for an eye disability, to include diplopia pursuant to 38 U.S.C.A. § 1151. His primary contention is that his eye disability is caused by diabetic tele-retinal examination that was administered at VA. A January 2014 VA examiner reviewed the claims file and determined that “there is no evidence of carelessness, negligence, lack of skill, error in judgment or other instance of fault by the care team.” He indicated that the Veteran’s double vision “cannot conceivably cause diplopia several days later.” He noted that although a subsequent examination showed that the Veteran a right hypertropia that was causing double vision, “this is not known to be caused by camera or dilating drops.” The examiner did not provide adequate rationale for his opinion; therefore, another VA opinion is necessary. The examiner also noted that “it is impossible to know what the diagnosis was for certain but judging by the history and exam findings” it is likely that the Veteran developed microvascular disease that led to fourth cranial nerve palsy that caused the symptoms, which is common with patients with uncontrolled diabetes. Therefore, the VA medical opinion should provide an opinion regarding the relationship, if any, between the eye disability and diabetes mellitus. The Board notes that during the March 2018 Board hearing, the Veteran testified that a private physician noted that double vision can be caused by x-ray machines; however, the Veteran did not provide the private physician’s statement. As the Board is remanding the claim, the Veteran should be afforded the opportunity to provide such evidence. 5. Entitlement to compensation pursuant to 38 U.S.C. § 1151 for diabetes mellitus claimed as the result of VA treatment, to include prescribed medication is remanded. 6. Entitlement to compensation pursuant to 38 U.S.C. § 1151 for residuals of a stroke, claimed as the result of VA treatment, to include prescribed medication is remanded. 7. Entitlement to compensation pursuant to 38 U.S.C. § 1151 for a heart disability claimed as the result of VA treatment, to include prescribed medication is remanded. 8. Entitlement to compensation pursuant to 38 U.S.C. § 1151 for a headache disability claimed as the result of VA treatment, to include prescribed medication is remanded. 9. Entitlement to compensation pursuant to 38 U.S.C. § 1151 for a subdural hematoma claimed as the result of VA treatment, to include prescribed medication is remanded. The Veteran contends that the remaining disabilities (diabetes, residuals of stroke, heart, headache disability and subdural hematoma) are caused by medications prescribed by VA, to include Seroquel (Quetiapine), Xanax, hydro codeine, and others. The Board finds that a VA medical opinion in needed regarding these contentions. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for any facilities that have provided him treatment for his claimed disabilities, to include the Red River Regional Hospital. Make two requests for the authorized records from any identified facility, unless it is clear after the first request that a second request would be futile. 2. Obtain updated VA treatment records. 3. Obtain from SSA copies of their determination on the Veteran’s claim for SSA disability benefits and the record upon which the determination was made. If such records are unavailable, the reason for their unavailability must be explained for the record. 4. Upon completion of directives #1 - #3, schedule the Veteran for VA examination to determine the etiology of his arthritis. The electronic records should be made available to and reviewed by the examiner(s). Any indicated studies should be performed. The clinician is asked to review the record and then respond to the following: Whether it is at least as likely as not (a 50 percent or greater probability) the Veteran’s arthritis is causally related to or aggravated by his left wrist disability, to include carpal tunnel syndrome. 5. Upon completion of directives #1 - #3, schedule the Veteran for VA examination(s) to determine the current nature and severity of his left wrist sprain and carpal tunnel syndrome of his left wrist. The electronic records should be made available to and reviewed by the examiner(s). Any indicated studies should be performed. 6. Upon completion of directives #1 - #3, schedule the Veteran for VA examination(s) by a medical doctor to determine the nature and etiology of his eye disability, diabetes mellitus, residuals of stroke, heart, headache disability and subdural hematoma from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner(s). If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. The clinician is asked to review the record and then respond to the following: (a.) Whether it is at least as likely as not (a 50 percent or greater probability) the Veteran’s eye disability was caused by VA treatment provided in 2015. (b.) Whether an eye disability was due to carelessness, negligence, lack of proper skill, error in judgment, or a similar instance of fault on the part of VA providers or was due to an event not reasonably foreseeable. (c.) Whether it is at least as likely as not (a 50 percent or greater probability) the Veteran’s eye disability is caused or aggravated by diabetes mellitus. (d.) Whether it is at least as likely as not (a 50 percent or greater probability) the Veteran’s diabetes mellitus, residuals of a stroke, heart disability, headache disability and/or subdural hematoma was caused by any medications, to include Seroquel, Xanax, Hydro codeine, metoprolol and any others, as prescribed by VA treating providers. (e.) Whether diabetes mellitus, residuals of a stroke, heart disability, headache disability and/or subdural hematoma was due to carelessness, negligence, lack of proper skill, error in judgment, or a similar instance of fault on the part of VA providers or was due to an event not reasonably foreseeable. ( Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Hemphill, Associate Counsel