Citation Nr: 21000441 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 16-62 767 DATE: January 5, 2021 REMANDED Whether new and material evidence has been received to reopen a claim for service connection for diabetes mellitus is remanded. Whether new and material evidence has been received to reopen a claim for service connection for hypertensive vascular disease (previously claimed as high blood pressure) is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for a cervical spine disorder is remanded. Entitlement to service connection for a lumbar spine disorder is remanded. Entitlement to service connection for a bilateral shoulder disorder is remanded. Entitlement to service connection for bilateral elbow arthritis is remanded. Entitlement to service connection for bilateral wrist arthritis is remanded. Entitlement to service connection for a left ankle disorder is remanded. Entitlement to service connection for bilateral upper extremity and lower extremity neuropathy (claimed as secondary to diabetes mellitus) is remanded. Entitlement to service connection for chronic obstructive pulmonary disease (COPD) is remanded. Entitlement to service connection for obstructive sleep apnea is remanded. Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for an acquired psychiatric disorder other than PTSD is remanded. Entitlement to an evaluation in excess of 30 percent for bronchial asthma is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served in the Puerto Rico Army National Guard from 1963 to 1966 and from 1977 to 1999, which included a period of active duty for training from July 1963 to February 1964. He also served on active duty in the United States Army from October 1977 to January 1978. This case comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2016 rating decision by the Department of Veterans Affairs (VA). In a March 2020 decision, the Board decided one issue on appeal and remanded the remaining issues above for further development. The case has since been returned to the Board for appellate review. On review, the Board finds that additional development is necessary prior to final adjudication of the Veteran’s claims. Specifically, the agency of original jurisdiction (AOJ) did obtain VA treatment records in response to the Board’s prior remand; however, it appears that there may still be outstanding treatment records, as detailed in the directives below. See Stegall v. West, 11 Vet. App. 268 (1998). The Board also instructed the AOJ to schedule the Veteran for a new VA examination for the bronchial asthma and COPD claims. The record indicates that the examination request remained pending until October 2020 due to COVID-19 restrictions, then was cancelled shortly thereafter at the Veteran’s request. See October 2020 VA Exam Scheduling memorandum. Nevertheless, the record contains no communication with the Veteran documenting that he made such a request, such as a written correspondence, email, or VA-Form 27-0820 memorializing a phone call. Based on the foregoing, the Veteran should be afforded another opportunity to appear for a VA examination for these claims or a direct communication with the Veteran showing his desire to not addend an examination should be documented and added to the record. The case is REMANDED for the following actions: 1. Secure copies of the paper VA treatment records dated from 1991 to 2000 noted to have been mailed in the August 2020 7131 response. A new request should be made for the records if necessary. 2. Secure any outstanding VA pulmonary function test (PFT) results from 2014 to present, including any reports contained in the Computerized Patient Record System (CPRS) Tools/Vista Imaging. See, e.g., October 2018 VA treatment record (noted PFTs performed in 2016 and 2018). 3. Schedule the Veteran for a VA respiratory conditions examination to determine the nature and etiology of his COPD and to ascertain the current severity of his service-connected bronchial asthma. Any studies, tests, and evaluations deemed necessary by the examiner should be performed, including PFTs. The examination should be scheduled at a time when the Veteran has returned to Pennsylvania, unless he otherwise notifies VA that he has moved to another jurisdiction. The most recent correspondence from the Veteran in August 2020 shows his mailing address continues to be the address in Philadelphia. See VA treatment records from December 2017 (noted displaced from Puerto Rico due to hurricane; appears to be living with family in Pennsylvania) and June 2020 (noted Veteran was in Puerto Rico and not sure when he would be returning to Pennsylvania). If the Veteran informs the AOJ that he does not wish to appear for a VA examination after receiving notification of the newly scheduled examination, documentation of direct communication with or from him must be included in the claims file. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. After a review of the pertinent records associated with the claims file, the examiner should address the following: (a) It is at least as likely as not that the Veteran’s service-connected bronchial asthma caused his COPD? (b) Is it at least as likely as not that the Veteran’s service-connected bronchial asthma has aggravated his COPD? (c) If the COPD is not due to or aggravated by the bronchial asthma, the examiner should indicate which portion of the Veteran’s symptoms, impairment, and PFT results are attributable to the service-connected bronchial asthma, as opposed to the COPD, or whether it is not possible to make this distinction. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Copies of all pertinent records in the Veteran’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. DUSTIN L. WARE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Postek, 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.