Citation Nr: 20028055 Decision Date: 04/22/20 Archive Date: 04/22/20 DOCKET NO. 17-01 785 DATE: April 22, 2020 REMANDED Service connection for a central nervous system disease (including chronic inflammatory demyelinating polyneuropathy (CIDP)) is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1985 to December 1987. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a June 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office in San Diego, California. On June 11, 2019, a hearing was held before the undersigned Veterans Law Judge and the transcript is associated with the record. On March 1, 2019, the Veteran was mailed notice that he must request to change representation within 90 days of that mailing. See also 38 C.F.R. § 20.1304 (2018). On June 21, 2019, the Veteran chose to a new representative. See June 2019 VA Form 21-22. Although this attempt to change representation arrived after the 90-day deadline, the Board granted the Veteran’s change and his new representative was afforded an opportunity to provide an additional Appellant Brief, which has been associated with the claims file. See March 2020 Appellant’s Brief. To provide the broadest and most sympathetic review, the claim on appeal has been re-characterized as noted above. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (Board must consider any disability that “may reasonably be encompassed by” a description of the claim, symptoms reported, and other evidence). 1. Service connection for a central nervous system disease (including CIDP) is remanded. The Veteran’s VA treatment records note diagnoses of CIPD, e.g., August 2014 VA treatment records; he reported receiving vaccinations on active duty, see June 2019 Board hearing; and a private medical linkage (nexus) opinion indicated that his CIPD may be associated with the vaccinations see August 2019 private opinion. However, the private opinion is conclusory (did not explain why the opinion provider came to this conclusion) and, therefore, although it is sufficient to support the Board’s finding that a medical examination and opinion must be provided, the Board is not allowed to use the private opinion to grant service connection. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of an opinion comes from its rationale or underlying reasoning). Therefore, the issue is remanded to provide the Veteran a VA examination because he has not received one for this issue. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Board acknowledges the disruption this disability has caused in the Veteran’s life, especially given the reported unlikely onset (due to his reported pre-service athleticism, occupational background, and the lack of family history of illness like this). The Board appreciates the Veteran’s service and his efforts to submit evidence and explain theories of entitlement while living with this significant disability. He truly partnered with VA in developing his claim. The matters are REMANDED for the following action: 1. Please note that, by law, ALL remanded claims must be processed expeditiously. 2. Then, forward the record with the updated evidence for an opinion from an appropriate examiner, preferably a neurologist or even a neuro-immunologist, to evaluate the nature and cause of his reported CIDP or similar disorder. Please answer the following questions based on (1) a review of the claims file, (2) interview and examination of the Veteran, and (3) any needed diagnostic testing. a) Identify any CIDP or similar central nervous system disorder. Any needed diagnostic testing should be performed. If any previously documented diagnoses are no longer believed to apply (e.g., see the brief factual background below), the examiner must explain why, citing to the pertinent diagnostic criteria. b) Is it at least as likely as not (a 50 percent or better probability) that any diagnosed CIDP or similar central nervous system disability had its onset in active service OR is otherwise related to the Veteran’s service (especially a delayed onset resulting from vaccinations received in service)? In answering question b, please elicit, report, and refer to the Veteran’s description of symptom onset and progression AND review and discuss the below evidence provided by the Veteran including his August 2019 private medical opinion and the article excerpts that he provided connecting CIDP (and GBS) with immunizations (see below). The examiner’s attention is drawn to the following records (the following is a brief factual background and not intended to be a substitute for your review of the claims folder): • January 2012 private Electromyography (EMG) impression noted results consistent with CIDP. • VA treatment records: For example: o June 2013 VA neurology consult: VA neurologist noted diagnosis of CIDP 1.5 years earlier after EMG. Assessed possible CIPD but suggested AIDP (BGS). o January 2014 neurology follow-up: A VA neurologist noted “[p]ossible CIDP and not GBS.” o January 2014 VA treatment records: The Veteran reported subtle symptoms began 12-13 years prior and pain and balancing issues 5-6 years prior. o November 2014 neurology EMG consult: “There is evidence supportive of Chronic demyelinating greater than axonal sensorimotor polyneuropathy with conductive blocks, consistent with CIDP.” o Many VA treatment records have noted history of CIPD or diagnosed CIDP. E.g. August 2014 Outpatient clinic note and October 2015 primary care note (“CIPD: confirmed on EMG/NCV.)” • March 2015 Statement in support of claim: The Veteran reported a theory of entitlement that he has received advice from medical professionals that this CIDP could be the result of vaccinations received while in service. • January 2015 article from GBS/CIDP Foundation International, “Flu shots and GBS. [Appears only pages 1 and 2 of 8 were provided by the Veteran.] • September 2006, Journal of Clinical Neuromuscular Disease: Volume 8-Issue 1, pages 20-25. The Veteran only appeared to provide a copy of a brief overview. “Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) With Rapid Progression after Influenza Vaccine: a Report of Three Cases.” • “Age and Aging 2008: 37: ” pages 229-230. “Post influenza vaccine chronic inflammatory demyelinating polyneuropathy” • April 2003, ARCH NEUROL – Volume 60 (www.archneurol.com). Only pages 504 and 509 appear to be provided by the Veteran, “Vaccines and Risk of Central Nervous System Demyelinating Diseases in Adults.” • “Acta Neurol Belg (2013) 113:519-522.” Only pages 521 and 522 appear to be provided by the Veteran. [From public sources this appeared to be from an article titled “Chronic inflammatory demyelinating polyneuropathy (CIDP) associated to hereditary neuropathy with liability to pressure policies (HNPP) and revealed after influenza AH1N1 vaccination.”] • August 2019 private medical nexus opinion. The examiner should confirm that the claims file was reviewed. Applicable medical research and literature should also be consulted and used to support conclusions. Please note that the Veteran is qualified to report observable symptoms, and, for the purposes of this examination, please assume the Veteran’s reports to be credible. [CONTINUED ON NEXT PAGE] A detailed explanation (rationale) is required for all opinions provided and is very much appreciated. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation.) VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board David Arritt, 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.