Citation Nr: 20049977 Decision Date: 07/28/20 Archive Date: 07/28/20 DOCKET NO. 11-25 548 DATE: July 28, 2020 REMANDED Entitlement to service connection for neuralgia due to maxillary expansion surgery is remanded. REASONS FOR REMAND The Veteran had active service from February 1986 to January 1990. In March 2013 the Veteran testified before a Veterans Law Judge (VLJ) at a videoconference hearing. A transcript is of record. The VLJ who conducted the March 2013 hearing is no longer employed by the Board. The Veteran did not reply to an April 2020 letter from the Board regarding whether she wished to testify at a Board hearing before another VLJ. Therefore, the Board will proceed with the present decision without the Veteran being scheduled for a new hearing. This claim was previously before the Board in October 2014, at which time the Board remanded it for additional development. Additional development is needed before the claim can be decided on the merits. Entitlement to service connection for neuralgia due to maxillary expansion surgery is remanded. The Veteran is seeking service connection for jaw pain and neuralgia due to maxillary expansion surgery during service. The Veteran’s private treating dentist, Dr. S., wrote in October 2005 that oral surgeons and an endodontist whom the Veteran was referred to opined that she was experiencing neuralgia. Dr. S. recommended that the Veteran be seen by a neurologist to determine if she had a neuralgia. In December 2008 Dr. S wrote that the cause of the Veteran’s discomfort could not be determined and that some form of neuralgia was suspected. November 2005 treatment records from Moody Air Force Base show a diagnosis of “unclear neuralgia” that had been diagnosed by Dr. S. with subsequent evaluation by multiple providers. In August 2009 the Veteran had a VA dental examination. The examiner wrote in September 2009 that the Veteran had pain following the distribution of the facial nerve, including of the temporalis, and extending to the cervical area. Furthermore, the examiner agreed with the assessment of the private dentist that the Veteran’s condition was most likely neurologic in origin. The Veteran had a VA neurological disorders examination in October 2009. The examiner opined that there was no evidence of neuralgia. It was noted that the Veteran had atypical facial pain in the headache classification code that first began on the left and had become persistent on the right side. It did not follow a specific nerve distribution. The etiology was unclear and was less likely than not caused by or a result of the in-service maxillary surgery. Dr. S. wrote in June 2011 that the origins of the Veteran’s maxillary pain had not been pinpointed. Due to the extent of the maxillofacial surgery, Dr. S. assumed that the pain could be neuralgia, and that the in-service surgery could not be definitely ruled out as a cause of the pain. In October 2014 the Board remanded the claim for the Veteran to be scheduled for a new VA examination, preferably with a neurologist. The examiner was to offer an opinion on the Veteran’s diagnosis during the appeals period, including confirming or ruling out a diagnosis of neuralgia, and an opinion on the relationship to service, including the maxillary expansion surgery. Furthermore, the examiner was to discuss the October 2005 statement from Dr. S and the September 2009 VA examiner’s report. At June 2015 private ear, nose, and throat treatment the Veteran complained of ten years of pain in the area of the 1988 oral maxillofacial surgery. The impression was vasomotor rhinitis and facial pain. It was recommended that the Veteran go to an oral surgeon for an evaluation. In September 2019 Dr. S. wrote that the Veteran was still having maxillary pain on her left side. Dr. S. further wrote that he “assume[s] and believes it should not be ruled out that it is neuralgia that resulted from the surgery.” He recommended that the Veteran be evaluated by a neurologist to determine if it is neuralgia. The Veteran had a dental examination arranged through VA in January 2020 at which it was noted that she had never been diagnosed with an oral or dental condition. She reported that the pain on the left side of her jaw had worsened and radiated down her neck. The examiner opined that the condition was less likely than not incurred in or caused by the claimed in-service injury event or illness. She further wrote that she agrees with the dental specialists and neurologist who failed to make a definitive diagnosis and that the symptoms were not related to the 1988 surgery. However, the examiner also wrote that the Veteran may need to be referred back to a neurologist for further testing and that she could not specify the source of the pain. After 32 years she doubted that the surgery was the cause of the pain. Significant probative value cannot be given to the January 2020 examiner’s opinion because the examiner wrote that the Veteran may need to be referred back to a neurologist for further testing. Furthermore, the examiner did not discuss the October 2005 letter from Dr. S. stating that the Veteran had neuralgia, as instructed in the Board’s October 2014 remand. Compliance by the Board or the RO with remand instructions is neither optional nor discretionary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran must be scheduled for a neurological examination before the claim can be decided on the merits. The matters are REMANDED for the following action: Schedule the Veteran for a neurological examination to determine the nature and etiology of the left jaw pain. The examiner must be given full access to the Veteran’s complete VA claims file and the Veteran’s electronic records for review. The examiner must diagnosis any disability resulting in the Veteran’s reported jaw/facial pain, present at any time during the appeal period (November 2008 to present). The examiner should specifically confirm or rule out a diagnosis of neuralgia. The examiner must opine whether it is at least as likely as not (50 percent or greater probability) that any diagnosed disability causing jaw pain, or if there is no diagnosis, any functional impairment of the jaw, is related to service, to include the Veteran’s in-service maxillary expansion surgery. The examiner must discuss the medical rationale for all opinions expressed, whether favorable or unfavorable, if necessary, citing to specific evidence in the file. The October 2005 letter from Dr. S. regarding the Veteran having neuralgia and the September 2009 examination report in which the examiner described the Veteran’s reported pain as following the distribution of the facial nerve, inclusive of the temporalis, and extending to the cervical area, should be considered and discussed. The examiner is advised that the term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it. If the examiner cannot provide his or her requested opinion without resorting to speculation, he or she should state why that is the case. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Scott Shoreman, 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.