Citation Nr: 21000108 Decision Date: 01/04/21 Archive Date: 01/04/21 DOCKET NO. 15-03 808A DATE: January 4, 2021 REMANDED The issue of entitlement to service connection for tremor is remanded. The issue of entitlement to service connection for peripheral neuropathy, bilateral feet, is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1965 to March 1967, including service in the Republic of Vietnam. In March 2018, the Veteran testified under oath before the undersigned Veterans Law Judge at a video conference hearing. A transcript of the hearing is of record. In April 2020, the Board remanded the issues on appeal for additional development. For the reasons outlined below, the Board finds that remand is again needed. 1. Entitlement to service connection for tremor. 2. Entitlement to service connection for peripheral neuropathy, bilateral feet. The Board finds that additional development is needed prior to final adjudication of the issues on appeal. Specifically, the Board finds that an addendum opinion is needed. In April 2020, the Board remanded the appeal for an opinion that addressed, inter alia, the Veteran’s contention at the March 2018 videoconference hearing that he noticed symptoms in his feet shortly after returning from his service in the Republic of Vietnam. However, the April 2020 addendum opinion obtained does not address these contentions. Accordingly, the Board asks that the Veteran’s contentions be addressed upon remand. Further, the Board seeks a more robust rationale regarding the potential nexus between the Veteran’s claimed tremors and his conceded in-service exposure to herbicide agents. The Board acknowledges the April 2020 VA opinion, but finds that the rationale appears to conflate the Veteran’s tremors claim with his claim regarding peripheral neuropathy. For example, in the April 2020 opinion, the examiner wrote: There are no tremors documented while in service or proximate to service. The veteran reported onset of tremors 4/18/01 and was documented with each essential tremors. The veteran does not have Parkinson’s disease, per the DBQ and subsequent records. Agent Orange has been linked with peripheral neuropathy. However, any peripheral neuropathy due to exposures be likely to manifest at the time of exposure or proximate to those exposures. Therefore, it is less likely than not that the veteran’s essential tremor is due to, incurred in or caused by service or exposures, including agent orange, while in service. Furthermore, the veteran’s tremors are not considered due to a peripheral neuropathy. (Emphasis added). It is unclear to the Board how the conclusion “it is less likely than not that the veteran’s essential tremor is due to, incurred in or caused by service” follows from “any peripheral neuropathy due to exposures be likely to manifest at the time of exposure or proximate to those exposures.” Accordingly, upon remand, the Board asks that new addendum opinions be obtained that address each of the Veteran’s claimed service-connected disabilities separately (unless there is a medically determined reason why they should be conflated), and provides detailed rationales specific to each claimed disability. In addition, in the April 2020 remand, the Board asked that the examiner address articles provided by the Veteran. In response, the examiner wrote: “The articles supplied by the veteran are not widely accepted, peer-reviewed studies which are required for acceptance by the medical community.” The Board notes that one of the articles submitted by the Veteran, in February 2013, is cited as from the Institute of Medicine for the National Academies, and another has a web address from “nih.gov.” This suggests to the Board that a more thorough examination of the Veteran’s articles is needed. Accordingly, the Board asks again upon remand that these articles be addressed. Finally, the Board notes that in the Veteran’s August 1964 pre-induction examination, there is a notation indicating “abnormal” lower extremities (except feet) (strength, range of motion). The Board asks that this notation be addressed upon remand. The matters are REMANDED for the following action: 1. After securing any necessary consent forms from the Veteran, obtain any outstanding treatment records, to include any VA and/or private treatment records, pertaining to the issues on appeal. All efforts should be documented in the claim file. If any records could not be obtained, this should be noted in the claim file. 2. Upon completion of the above, obtain the following new opinions: (a) An opinion that addresses the etiology of the claimed tremors disability. For each disability diagnosed, the examiner is asked to address whether it is at least as likely as not (i.e., a 50 percent or greater probability) that it was caused by the Veteran’s active duty service, to include his conceded exposure to herbicide agents in the Republic of Vietnam. (b) An opinion that addresses the etiology of the claimed peripheral neuropathy, bilateral feet, disability. Specifically, the examiner should address: (1) Whether it is at least as likely as not that the disability clearly and unmistakably pre-existed service. The Board notes that in the Veteran’s August 1964 pre-induction examination, there is a notation indicating “abnormal” lower extremities (except feet) (strength, range of motion). The Board asks that this notation be addressed. (2) If there is clear and unmistakable evidence that the claimed disability preexisted service, then the examiner should address whether there is clear and unmistakable evidence that the claimed disability was not permanently aggravated by service. If not, the examiner should then address whether it is at least as likely as not that it was caused by the Veteran’s active duty service. The Board notes that a preexisting injury or disease will be considered to have been aggravated by active service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. See 38 C.F.R. § 3.306 (a). (3) If it is determined that the disability did not clearly and unmistakably preexist service, then the examiner should address whether it is at least as likely as not that it was caused by the Veteran’s active duty service. The examiner is asked to address the following as well: (1) the Veteran’s testimony at the March 2018 videoconference hearing, where he indicated that he noticed symptoms in his feet shortly after returning from Vietnam; (2) a May 1965 notation in the service treatment records that reports a sore ankle. Finally, in rendering the opinions, it is requested that the examiner address the articles provided by the Veteran regarding Agent Orange. The Veteran submitted several articles in February 2013, as well as an article entitled, “Agent Orange & Its Neurological Symptoms,” in May 2013. The examiner is asked to respond to these articles. The VA examiner should be given access to the claim file, including a copy of this remand. The examiner should state that a review of the claim file was completed. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. A detailed rationale is requested for all opinions provided.   3. If upon completion of the above action the issues are denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Foster, 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.