Citation Nr: 20021827 Decision Date: 03/27/20 Archive Date: 03/27/20 DOCKET NO. 18-09 370 DATE: March 27, 2020 REMANDED The issue of entitlement to service connection for left upper extremity disability, to include tremors and peripheral neuropathy is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1967 to September 1971. He served in Vietnam and his military awards include the Combat Action Ribbon. The Board previously remanded the issue for further development in May 2019 and September 2019. The case has now been returned to the Board for appellate review. To afford the Veteran the broadest possible scope for his claim of entitlement to a left upper extremity disability, the issue has been recharacterized accordingly to that of entitlement to service connection for left upper extremity disability, to include tremors and peripheral neuropathy. Clemons v. Shinseki, 23 Vet. App. 1,6 (2009). The issue of entitlement to service connection for left upper extremity disability, to include tremors and peripheral neuropathy is remanded. The Veteran contends that he has a left upper extremity disability that is related to peripheral artery disease caused by his service-connected coronary artery disease. Alternatively, he maintains that the left upper extremity condition, particularly tingling in the hand, is caused or aggravated by medications he has been taking for his service-connected disabilities. See February 2020 Representative Brief, at 3. The Veteran reports symptoms of shaking in his left hand, a sharp pain shooting up his fingers when he has tremors, tingling and numbness in his hand and fingers. The Veteran has been prescribed with warfarin to treat his coronary artery disease. A review of the June 2019 and October 2019 VA examination reports indicates that the Veteran’s symptoms of tingling and numbness in the left hand and fingers (not in the right hand) have not been fully explained by the examiners, aside from the determination that the Veteran does not have peripheral neuropathy. These symptoms have not been attributed to the tremors (a disorder of central nervous system). Therefore, an addendum opinion is required to ascertain any diagnosis for a disability productive of the tingling and numbness in the Veteran’s left hand and fingers. If no definitive diagnosis is ascertainable, then an opinion on whether these symptoms cause functional impairment of earning capacity must be provided. See, e.g., Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018) (recognizing pain as a disability if there is objective evidence of functional impairment of earning capacity). The Veteran’s representative states that warfarin and coronary artery disease have caused stomach pain, gas, gloating, and other gastrointestinal problems and the Veteran is prescribed with omeprazole. The representative contends that since a side effect of omeprazole is tremors, the Veteran’s essential tremors should be proximately due to his service-connected coronary artery disease. In support of this theory, several articles have been associated with the Veteran’s claims file. See February 2020 Representative Brief. Neither the Board nor the Veteran/his representative has medical expertise to provide such a nexus opinion. A remand is required for an addendum medical opinion to address this specific contention as well as nexus between his left upper extremity disability and any medications he takes for his service-connected disabilities. The matter is REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s left upper extremity disability, manifested by symptoms of tremors and tingling and numbness in the left hand and fingers. The examiner must opine whether tingling and numbness can be accounted for by the diagnosis of essential tremors or if the symptoms of tingling and numbness warrants a separate diagnosis. If the tingling and numbness are not explained by the tremors or no separate diagnosis is warranted, the examiner must opine if the symptoms of tingling and numbness cause functional impairment of earning capacity. If a separate diagnosis is made for the tingling and numbness or these symptoms cause functional impairment to earning capacity, the examiner must opine if the diagnosis or condition of tingling and numbness is proximately due to or aggravated by coronary artery disease, claudication of the lower extremities, or any medications the Veteran takes for his service-connected disabilities. The examiner must opine if the disability productive of tingling and numbness is caused by or otherwise related to his service, to include his presumed herbicide exposure in service. As for the diagnosed condition of tremors, the examiner must opine if the tremors are proximately due to or aggravated by any medications the Veteran takes for his service-connected disabilities. When providing opinion for impact of medications, the examiner must also opine if the Veteran’s gastrointestinal problems, treated by omeprazole, are caused by warfarin, which the Veteran takes for his service-connected coronary artery disease and if omeprazole is causing his tremors or tingling and numbness in the left hand and fingers. If the examiner determines that another VA examination is needed to provide the above opinions, the AOJ must schedule a VA examination and obtain opinions requested above. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Y. Taylor, 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.