Citation Nr: 20004875 Decision Date: 01/22/20 Archive Date: 01/21/20 DOCKET NO. 16-62 520 DATE: January 22, 2020 REMANDED Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for a neuromuscular disorder due to an allergic reaction to the flu shot is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1979 to August 1983, and February 2003 to August 2004. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in May 2016 by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2019, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. At such time, the Veteran waived Agency of Original Jurisdiction (AOJ) consideration of evidence associated with the record since the issuance of the November 2016 statement of the case. 38 C.F.R. § 20.1304(c). Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for a neuromuscular disorder due to an allergic reaction to the flu shot. The Veteran contends that she has a neuromuscular disorder as a result of her military service. Specifically, she alleges that she had an allergic reaction to a flu shot she received while stationed in Germany in 1983 and immediately developed paralysis throughout her body, which results in current residuals of numbness, tingling, and weakness in her upper extremities. As an initial matter, the Board finds that a remand is necessary in order to obtain potentially outstanding service records. In this regard, at the July 2019 Board hearing, the Veteran stated that she was hospitalized for two weeks and under quarantine for an additional three weeks at the Army hospital in Vilseck, Germany, after receiving the flu shot in 1983. However, such records are not on file and it does not appear that efforts have been made to obtain them. Thus, a remand is warranted for the AOJ to attempt to obtain such records. Additionally, after the receipt of any additional service department records obtained in connection with the aforementioned request, the AOJ should afford the Veteran a VA examination so as to determine the nature and etiology of her claimed neuromuscular disorder. In this regard, the Veteran’s service treatment records (STRs) reflect that she was allergic to the flu shot. See February 2003 and August 2003 STRs. Furthermore, at the July 2019 Board hearing, she stated that she currently had numbness, tingling, and weakness in her upper extremities. In this regard, the Board notes that the Veteran is currently service-connected for cold weather injury of her the bilateral hands. However, she testified that her symptoms were not triggered by severe cold weather or anything of that nature. Therefore, the Board finds that a VA examination is needed to determine if the Veteran has a neuromuscular disorder as a residual from her allergic reaction to the flu shot during service that is separate and distinct from her already service-connected cold weather injuries. The matters are REMANDED for the following action: 1. Obtain the Veteran’s hospitalization and quarantine records from 1983 from the Army hospital in Vilseck, Germany, from any appropriate source. Such may include requesting clinical records, which are usually filed under the facility name rather than a service member’s name. All attempts to procure these records should be documented in the file. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should also be documented in the claims file. The Veteran is to be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 C.F.R. § 3.159(e). 2. After the receipt of any additional service department records obtained in connection with the aforementioned request, the Veteran should be afforded an appropriate VA examination in order to determine the nature and etiology of her claimed neuromuscular disorder. The record, to include a copy of this Remand, must be made available to the examiner, and any indicated evaluations, studies, and tests should be conducted. Following a full review of the record, the examiner should address the following inquiries: (A) Please determine if the Veteran has a current neuromuscular disorder that is separate and distinct from her already service-connected cold weather injuries of the bilateral hands. In this regard, the examiner should address the Veteran’s contention that she has numbness, tingling, and weakness in her upper extremities that are not triggered by severe cold weather. (B) For each identified neuromuscular disorder, the examiner should opine whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such disorder had its onset in, or is otherwise related to, the Veteran’s military service, to include having an allergic reaction to the flu shot. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Clark, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.