Citation Nr: 18117118 Decision Date: 07/10/18 Archive Date: 07/09/18 DOCKET NO. 17-40 596 DATE: July 10, 2018 REMANDED Entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as due to exposure to herbicides and/or as secondary to the service-connected heart disability, is remanded. Entitlement to service connection for peripheral neuropathy of the right upper extremity, to include as due to exposure to herbicides and/or as secondary to the service-connected heart disability, is remanded. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as due to exposure to herbicides and/or as secondary to the service-connected heart disability, is remanded. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as due to exposure to herbicides and/or as secondary to the service-connected heart disability, is remanded. Entitlement to a TDIU is remanded.   REASONS FOR REMAND This case was previously before the Board in April 2018, when it was remanded so the Agency of Original Jurisdiction (AOJ) could further assist the Veteran with its development, to include obtaining an addendum opinion to the October 2017 VA examination report. The Board finds that there has not been the required substantial compliance with the April 2018 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998); D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); and, Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Accordingly, these claims must again be remanded for the reasons described further below. 1. Entitlement to service connection for peripheral neuropathy of the bilateral [i.e. left and right] upper and lower extremities. The Board finds that further development of the medical evidence is required prior to adjudicating the Veteran’s service connection claims for peripheral neuropathy of the bilateral upper and lower extremities. Where VA provides the Veteran with an examination in a service connection claim, such examination must be adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Pertinently, in April 2018, the VA examiner who had conducted the October 2017 VA examination submitted an addendum medical opinion. However, the Board finds that the examiner, again, did not provide an adequate rationale in support of her ultimate determination that a nexus between these claimed conditions and the Veteran’s service, to include his service-connected heart condition, does not exist. Succinctly, the examiner’s addendum opinion is a conclusory statement without any supporting rationale. See Neives-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that most of the probative value of an opinion comes from the discussion of its underlying reasoning or rationale); Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (“a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to a doctor’s opinion”); Additionally, both the October 2017 examination report and April 2018 addendum opinion do not indicate the type of peripheral neuropathy the Veteran has, which is necessary to properly opine on the relationship, if any, to the service-connected coronary artery disease. See June 2018 Atty. Stmt. (identifying medical literature that supports a relationship between peripheral neuropathy and coronary artery disease). As a result, considering these deficiencies, the Board finds that remand is necessary so that the Veteran can be afforded a new examination and opinion. 2. Entitlement to a TDIU. The TDIU claim is “inextricably intertwined” with the service connection claims currently before the Board and, thus, the TDIU claim must be deferred pending resolution of these other claims. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). Additionally, the Board sees that the Veteran was provided a VA heart conditions examination in June 2018. While his claim of entitlement to an increased rating for the service-connected coronary artery disease is not currently before the Board, review of the examination report suggests that a higher disability rating may be awarded by the AOJ. Further, the examination report also notes that the service-connected CAD has an impact on the Veteran’s employability. Consequently, the AOJ should adjudicate this increased rating claim prior to determining whether the need to refer the TDIU claim for extraschedular consideration is warranted. 3. Obtain current treatment records. Review of both April and October 2017 VA Peripheral Nerves Conditions DBQs show that relevant information regarding the Veteran’s current diagnosis were not available in VBMS or CPRS. Specifically, these examination reports both indicate that the Veteran was receiving treatment from his primary care doctor for his peripheral neuropathy. These records do not appear to be in the claims file. In fact, the April 2017 VA examiner noted that “there is no other documentation in VBMS of neuropathy or work-up for the etiology of the Veteran’s neuropathy.” Consequently, as the Board is remanding these claims for further development, the AOJ should also obtain the records of all relevant treatment [VA and private] the Veteran has received (the records of which have not already been obtained, so they, too, may be considered). See Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center(s), and obtain all outstanding treatment records if relevant to these claims. Also ask the Veteran to provide, or authorize VA to obtain, all relevant private medical records that have not been obtained. All efforts to obtain these records must be documented in the claim file and the Veteran properly notified if unable to obtain identified records. 38 C.F.R. § 3.159(c) and (e). 2. After receiving all additional treatment records, schedule the Veteran for the appropriate VA medical examinations addressing the nature and etiology of his claimed peripheral neuropathy of the bilateral upper and lower extremities. His claims file, including a copy of this remand, must be made available to the examining clinician in conjunction with this examination. All pertinent symptoms and findings must be reported in detail. Following review of the evidence of record, the clinical examination results, and the Veteran’s lay statements, the examiner must address the following: (a) Indicate the type of peripheral neuropathy that the Veteran is diagnosed with. If further specification is not possible, then the examiner should explain this finding. (b) It is at least as likely as not (50 percent or greater probability) that the Veteran’s peripheral neuropathy of the left upper, right upper, left lower, and/or right lower extremity was either caused, or aggravated, by his exposure to herbicides during active military service? The Board notes that the absence of delayed onset peripheral neuropathy from the list of presumptive conditions which are presumed to be the result of exposure to herbicides is not, by itself, a sufficient explanation for a negative opinion-i.e., if it is the examining clinician’s opinion that the Veteran’s current peripheral neuropathy is not associated with his exposure to an herbicide agent, then the examiner must do more to explain his or her opinion concerning the probability of a relationship between this particular Veteran’s peripheral neuropathy and his exposure to herbicides than to merely indicate that the Veteran is not entitled to a presumption for delayed onset peripheral neuropathy. (c) Alternatively, is it at least as likely as not that the Veteran’s service-connected coronary artery disease is either causing or aggravating his peripheral neuropathy of the left upper, right upper, left lower, and/or right lower extremity? The examiner should address the medical literature submitted in June 2018 by the Veteran’s representative, which identifies and addresses a relationship between coronary artery disease and ischemic peripheral neuropathy. When responding, the examiner should consider the lay statements of record regarding the nature and onset of symptoms. The examiner is advised that the Veteran is competent to report symptoms and treatment. All answers to the questions listed above must be supported by a clear rationale. The examiner is asked to explain in detail the underlying reasoning for his or her opinion, to include citing to relevant evidence, supporting factual data, prior medical opinions, and medical literature, as appropriate. If any requested opinion cannot be provided without resorting to mere speculation, the examiner must explain why a more definitive response is not possible or feasible. In other words, merely saying he or she cannot respond will not suffice. 3. Ensure the requested examination reports are responsive to the determinative issue of causation. If not, obtain all necessary additional information. Stegall v. West, 11 Vet. App. 268, 271 (1998); 38 C.F.R. § 4.2. M. H. HAWLEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jonathan Z. Morris, Associate Counsel