Citation Nr: 1807878 Decision Date: 02/07/18 Archive Date: 02/20/18 DOCKET NO. 15-13 705 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUE Entitlement to service connection for residuals of a cold injury. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD P. Nguyen, Associate Counsel INTRODUCTION The Veteran had a period of active service from February 1953 to February 1955. He served in the United States Army. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2013 rating decision by the Jackson, Mississippi, Regional Office (RO) of the Department of Veterans Affairs (VA). In December 2017, the Veteran appeared and provided testimony at a videoconference Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is associated with the record. The Veteran has requested that his case be advanced on the docket due to age. The motion to advance the case on the docket is granted. Please note that the case has been advanced on the docket pursuant to 38 C.F.R. § 20.900 (c) (2017). This appeal was processed using the Veterans Benefits Management System (VBMS) and the Legacy Content Manager (LCM) claims file. LCM contains additional VA treatment records but otherwise documents that are either duplicative of the evidence in VBMS or not relevant to the issue on appeal. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim and that he is afforded every possible consideration. 38 U.S.C. § 5103A (2014); 38 C.F.R. § 3.159 (2017). Remand is required for a new VA examination. Where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In this case, the Veteran has alleged that he suffered from a cold injury while on active service. His service personnel records demonstrate service in Korea for over one year. The Veteran testified at a December 2017 Board hearing that a VA physician had told him that his hand and feet issues were a result of his military service in Korea. The Veteran further testified that while he was walking guard on active duty, his feet would get cold and he could not keep them warm. He further testified that once he got off active duty, he continued to complain about having problems with his hands and feet as a result of cold weather, and that he is currently using creams and ointments to treat the cold weather injuries. A September 2013 VA examination was conducted, and the examiner indicated that the Veteran did not now have, nor ever had been, diagnosed with a cold injury. The VA examiner noted that the Veteran's service medical records (SMRs) were negative for a cold injury, and that the Veteran did not report signs or symptoms of cold injury. Upon diagnostic testing, the Veteran's bilateral hands showed osteoarthritis and subarticular punched out lesions. The Veteran's bilateral feet showed osteoarthritis. However, elsewhere in the examination report, the VA examiner indicated that the Veteran had other pertinent physical findings, complications, conditions, signs and/or symptoms resulting from a cold injury, including temperature sense decreased in stocking-glove distribution, vibration sense moderately impaired at the ankles, and onychomycosis involving all toe nails. See VA examination report, September 2013, pg. 6-7. The examiner then concluded that the Veteran had no residual symptoms of cold injury. The examiner found onychomycosis of the toenails was common in the population at large, that osteopenia is common in the elderly population at large, and that sensory loss in the feet was due to peripheral neuropathy, such that any opinion regarding cold injury residuals required speculation. A clarifying opinion is thus required. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of cold injury. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must elicit from the Veteran a full history and/or description of his active service. The examiner is asked to respond to the following: (a) Does the Veteran have residuals of a cold injury? The examiner is instructed to address the September 2013 VA Examination report, particularly the signs and symptoms identified in section 7b., and provide supporting rationale as to their etiology. The examiner must also address the onions provided in section 9. (b) For each currently diagnosed cold injury, is it at least as likely as not (50 percent or greater probability) that such is related to the Veteran's active service? 4. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim, and that the consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2017). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 5. Ensure compliance with the directives of this remand. If a report is deficient in any manner, the AOJ must implement corrective procedures. Stegall v. West, 11 Vet. App. 268, 271 (1998). 6. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim must be readjudicated. If the claim remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). _________________________________________________ K. MILLIKAN Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).