Citation Nr: 18161139 Decision Date: 12/28/18 Archive Date: 12/28/18 DOCKET NO. 16-23 237 DATE: December 28, 2018 REMANDED Entitlement to service connection for upper left extremity peripheral neuropathy is remanded. Entitlement to service connection for upper right extremity peripheral neuropathy is remanded. The appeal challenging the propriety of the reduction in the rating for bilateral hearing loss from 10 percent to noncompensable, effective February 1, 2017, is remanded. REFERRED At the July 2017 Board hearing, the Veteran indicated that he wished to submit a claim of entitlement to service connection for bilateral lower extremity peripheral neuropathy, to include as secondary to exposure to herbicide agents. The Veteran also indicated that he is not working. As such, he should be provided with the appropriate notice and application form to submit a claim of entitlement to a total disability rating based on individual unemployability. These issues are referred to the agency of original jurisdiction. REASONS FOR REMAND The Veteran served on active duty from July 1966 to July 1969, including service in the Republic of Vietnam. Peripheral Neuropathy The Veteran contends that he has right and left upper extremity peripheral neuropathy due to his exposure to herbicide agents, including Agent Orange, in Vietnam. The Veteran testified at a July 2017 Board hearing that he began having problems with neuropathy about 10 years ago. He stated that his left hand and right hand and arm were numb and that he had difficulty holding on to objects. The Veteran stated that he believed his peripheral neuropathy was caused by exposure to Agent Orange in Vietnam. Although the Veteran’s medical records do not indicate that he had upper extremity early onset peripheral neuropathy, and therefore the presumption that this disorder was caused by herbicide agents may not apply, the Board finds that a medical opinion should nonetheless be obtained to address whether any of the Veteran’s upper extremity symptoms are related to his in-service herbicide agent exposure. No opinion has yet been obtained addressing this question. The Board also notes that since the Veteran initially submitted his claim of entitlement to service connection for right and left upper extremity peripheral neuropathy, he has also been granted entitlement to service connection for ischemic heart disease and diabetes mellitus. The representative argued at the July 2017 Board hearing that the neuropathy could be related to diabetes, although the Veteran stated that his diabetes was largely under control. The Veteran’s VA treatment records show that in September 2010, the Veteran was diagnosed with neuropathy of the wrists due to carpal tunnel syndrome. It was noted that there was evidence of a mild underlying sensory neuropathy as well. The complete results of the September 2010 electromyographic nerve testing do not appear to have been associated with the record. An October 2016 VA examination for diabetes mellitus was held, and the examiner stated that the Veteran’s diabetes mellitus had no diagnosed complications and that the Veteran’s peripheral neuropathy was diagnosed by electromyographic testing in 2010 and preexisted his diabetes mellitus by six years. The Veteran’s physician, however, submitted a letter in August 2017 stating that the Veteran had bilateral hand and lower leg neuropathy, and that his neuropathy was related to his diabetes and years of prediabetes. He wrote that the Veteran had been prediabetic since at least May 2012. Because the record is currently unclear regarding whether the Veteran’s current symptomatology is primarily due to carpal tunnel syndrome which preexisted his diabetes mellitus, or due to diabetic neuropathy; and because the record is unclear as to whether any preexisting neuropathy was aggravated by diabetes mellitus, the Board remands this issue so that a new VA examination and opinion can be obtained. The examiner should address whether diabetes mellitus has caused or aggravated, even in part, the Veteran’s peripheral neuropathy symptoms, as well as whether these symptoms have been caused or aggravated by ischemic heart disease. All results from the September 2010 nerve testing should be obtained and associated with the record prior to obtaining this opinion so that these records can be reviewed by the examiner. Bilateral Hearing Loss In July 2011, entitlement to service connection for left ear hearing loss was granted and assigned a noncompensable rating. Entitlement to service connection for right ear hearing loss was denied because the Veteran’s right ear hearing levels did not rise to the level of a hearing loss disability for VA purposes. In August 2011, the Veteran submitted a notice of disagreement with the denial of service connection for right ear hearing loss. In November 2015, the Veteran’s hearing loss was reevaluated, and in an April 2016 rating decision, entitlement to service connection for right ear hearing loss was granted. The Veteran was assigned a 10 percent rating for bilateral hearing loss, effective November 2, 2015. In January 2017, the Veteran submitted a claim of entitlement to an increased rating for hearing loss, stating that his hearing loss disability had gotten worse. The Veteran attended a new VA examination in February 2017. Based on the results of the February 2017 VA examination, in a March 2017 rating decision, the Veteran’s evaluation for bilateral hearing loss was decreased to a noncompensable rate, effective February 1, 2017. The rating decision noted that the Veteran’s overall combined evaluation for compensation would remain unchanged at 70 percent. The Veteran has argued that his evaluation should not be reduced because his pure tone thresholds levels have decreased since his 2015 VA examination, and he has suggested that the speech discrimination scores recorded at the February 2017 VA examination were not an accurate assessment of his hearing loss abilities. At a July 2017 Board hearing, the Veteran stated that he felt that his VA examination in 2017 was inadequate and that the speech discrimination scores did not reflect his hearing loss abilities, because he frequently had to guess at what was being said during that test. The Veteran’s step-daughter stated that the appellant had a lot of difficulty understanding what people were saying and had to read lips. There are required procedures when a rating is reduced. In this case, the decrease of the Veteran’s evaluation for bilateral hearing loss did not result in a decrease in the overall amount of compensation payable to the Veteran, and the specific proposal notification regulations of 38 C.F.R. § 3.105(e) do not apply. Regardless of how long a rating has been in effect, however, a rating reduction requires an inquiry as to “whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based upon thorough examinations.” Brown v. Brown, 5 Vet. App. 413, 421 (1993). In this case, the Veteran has argued that his bilateral hearing loss disability has not actually undergone any improvement, and that he has actually had more functional impairment since 2015. Both he and his step-daughter have testified that he has a lot of difficulty understanding speech, and the Veteran has indicated that he believes the speech discrimination testing performed at the February 2017 VA examination are not representative of his hearing loss ability. The Board accepts the contentions of the Veteran and remands this issue so that another hearing loss examination can be performed in order to fully assess the current severity of the appellant’s hearing loss, and to ask the examiner to address whether the Veteran has actually demonstrated material improvement in the ability to function under the ordinary conditions of life and work. See Brown, 5 Vet. App. at 421. The matters are REMANDED for the following action: 1. Obtain all outstanding, pertinent VA treatment records from the Chillicothe VA Medical Center, the Dayton VA Medical Center, and the Wilmington Community-Based Outpatient Clinic since May 2018 and the EMG test results from September 2010 and any other outstanding nerve conduction test results. All records received should be associated with the claims file. If VA cannot locate all Federal records requested herein, it must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. Then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claim. The claimant must then be given an opportunity to respond. 2. Thereafter, arrange for the Veteran to undergo a VA examination with a physician to determine the nature and etiology of his upper extremity peripheral neuropathy. The examiner must be provided access to all files in Virtual VA/Legacy and VBMS. The examiner must specify in the report that these records have been reviewed. All indicated evaluations, studies, and tests should be conducted. The examiner should then address: What are the Veteran’s current neurological diagnoses relating to his upper extremities? If the Veteran has diagnoses of peripheral neuropathy, carpal tunnel syndrome and diabetic neuropathy, is it possible to differentiate the symptoms? For all diagnoses found, address whether it is at least as likely as not (50 percent or greater probability) that the disorder had its onset during, or is otherwise related to any disease or injury in the claimant’s service, including due to presumed exposure to herbicide agents in Vietnam. For all diagnoses found, address whether is it at least as likely as not that the disorder was (i) caused or (ii) is aggravated (worsened beyond the natural progression) by the Veteran’s service-connected diabetes mellitus or ischemic heart disease. A complete and fully explanatory rationale must be provided for any opinion offered. If any opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. 3. Schedule the Veteran for a VA audiological examination by an audiologist to determine the current severity of his service-connected hearing loss. All records in Virtual VA and VBMS must be provided to and reviewed by the examiner as part of the examination. All pertinent symptomatology and findings must be reported in detail. The examiner must review the Veteran’s past VA examinations, including the November 2015 VA examination, as well as VA treatment records. The examiner must specifically address whether since that examination the impact of the Veteran’s hearing loss disability has demonstrated a material improvement in the ability to function under the ordinary conditions of life and work. A complete and fully explanatory rationale must be provided for any opinion offered. If any opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the   record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. DEREK R. BROWN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Mary E. Rude, Counsel