Citation Nr: 21001544 Decision Date: 01/08/21 Archive Date: 01/08/21 DOCKET NO. 15-31 227A DATE: January 8, 2021 ORDER Entitlement to service connection for sciatica secondary to idiopathic lymphedema of right lower extremity is denied. REMANDED Entitlement to a rating in excess of 10 percent for idiopathic lymphedema left lower extremity is remanded. Entitlement to a rating in excess of 10 percent for idiopathic lymphedema right lower extremity is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDING OF FACT The Veteran’s sciatica is not caused or aggravated by her service-connected idiopathic lymphedema. CONCLUSION OF LAW The criteria for service connection for sciatica due to service-connected idiopathic lymphedema are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1980 to March 2000. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in June 2019. A hearing transcript is of record. In September 2019, the Board remanded the claims for further development. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310.   1. Entitlement to service connection for sciatica secondary to idiopathic lymphedema of right lower extremity is denied. The Veteran contends that her sciatica is secondary to her service-connected idiopathic lymphedema. See April 2016 Statement of Representative. Consistent with the Veteran’s contention, her service treatment records do not reflect diagnosis of sciatica or a lower back condition during active service, and there is no competent evidence suggesting the current sciatica disability onset in service or is otherwise related to service. See Robinson v. Mansfield, 21 Vet. App. 545, 552-56 (2008). Thus, the question for the Board is whether the Veteran’s sciatica is proximately due to or the result of, or aggravated beyond its natural progress by service-connected idiopathic lymphedema. The Board concludes that, while the Veteran has a current diagnosis of sciatica, the preponderance of the evidence is against finding the sciatica is proximately due to or the result of, or aggravated beyond its natural progression by service-connected idiopathic lymphedema. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). In an August 2019 private treatment record, the Veteran reported 5 months of intermittent right low back pain with sciatica in the right leg. The Veteran reported that when she wakes up in the morning, she has right thigh pain associated with muscle tightness, and difficulty with moving her leg. For the assessment, the clinician noted, “sciatica, right side: nerve impingement central vs peripheral.” The clinician also noted that the chronic leg edema is not related to ongoing back pain. The Veteran underwent a VA examination in January 2020. The Veteran was diagnosed with spinal stenosis and “radiculopathy lumbar spine, sciatica nerve, bilateral lower extremity.” The Veteran reported shooting pain from legs to the back, numbness and tingling in the legs, and stiffness in the back. The examiner opined that the claimed condition was less likely than not proximately due to or the result of, or aggravated beyond its natural progression, by the Veteran’s service-connected idiopathic lymphedema. The examiner explained that the two conditions are not medically related. The examiner noted that sciatica is an entirely separate entity from the service-connected idiopathic lymphedema, and that medical literature does not support a medical relationship between the two. The examiner noted that the Veteran’s sciatica is instead more likely due to her spinal stenosis. The examiner noted that the Veteran’s spinal stenosis can cause the pain in both legs. The examiner wrote that according to a 2014 medical article by Ammendolia C., “Degenerative lumbar spinal stenosis causing neurogenic claudication is a common condition impacting walking ability in older adults.” The examiner added that the service-connected idiopathic lymphedema also causes pain in the lower extremity, and not sciatica. The examiner concluded that a nexus has not been established. The Board finds the January 2020 VA opinion is competent and persuasive, as the examiner reviewed the relevant evidence, considered the contentions of the Veteran, and provided supporting rationale for the conclusion reached. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120 (2007). Further, the August 2019 private record also noted that the Veteran’s chronic leg edema is unrelated to her back pain, which supports the VA examiner’s rationale. There is no competent medical evidence attributing the Veteran’s sciatica to her service-connected idiopathic lymphedema. The Veteran believes her sciatica is caused or aggravated beyond its natural progression by her idiopathic lymphedema, but she is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge and interpretation of complicated diagnostic medical testing and anatomical relationships in the body. Therefore, it is outside the competence of the Veteran in this case because the record does not show that she has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the January 2020 VA examiner’s opinion. In sum, the preponderance of the evidence is against the claim and the benefit of the doubt rule is inapplicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection for sciatica secondary to idiopathic lymphedema of right lower extremity is not warranted. REASONS FOR REMAND 1. Entitlement to a rating in excess of 10 percent for idiopathic lymphedema left lower extremity is remanded. 2. Entitlement to a rating in excess of 10 percent for idiopathic lymphedema right lower extremity is remanded. The Veteran asserts that the symptoms of her idiopathic lymphedema warrant assignment of a higher rating. In the September 2019 remand, the Board found that the November 2014 VA examination report did not fully describe the Veteran’s disability sufficient for adjudication of the appeal under the relevant diagnostic code, which is DC 7101. The Veteran does not have varicose veins, but her disability is rated as analogous to such. The Board requested a new examination to determine the current severity of the Veteran’s idiopathic lymphedema of the bilateral lower extremities. In the remand directive, the examiner was requested to discuss the subjective symptoms reported by the Veteran in her January 2014 notice of disagreement (NOD), and comment on whether the symptomology described is related to her idiopathic lymphedema. The Veteran underwent a new VA examination in January 2020. The examination report noted symptoms of bilateral leg pain, tightness, and swelling and described the functional impact of the disability on the Veteran’s ability to work, but otherwise does not provide all necessary information to be able to fully adjudicate the appeal. While swelling was noted, the Veteran’s disability is rated under DC 7120 which rates relevant disabilities on the frequency and severity of symptoms of edema, stasis pigmentation, ulceration and eczema. The VA examination report does not clearly describe the severity of the chronic swelling as it pertains to rating the frequency and severity of edema consistent with DC 7120. With respect to the other skin symptoms reported by the Veteran in her January 2014 NOD (i.e. broken skin and painful fissures between the toes; repeated bouts of cellulitis; blisters and lesions on the soles of her feet; and advanced stages of cellulitis; cellulitis affecting her arm pit, groin areas, intense sunburn, swelling in the arms and fingers), these are not specifically addressed in the 2020 VA examination report. However, the Board does note that in a prior VA examination report from January 2013, a VA examiner indicated the Veteran had previously suffered from bouts of cellulitis, which was related to her service-connected idiopathic lymphedema. The VA and private medical records in the claims file do not reflect subjective complaints or objective findings consistent with the symptoms described in the January 2014 NOD, as least for the duration of relevant appeal period which is October 2011 forward. However, on remand the examiner is asked to clarify whether the in-person clinical evaluation of the Veteran at the January 2020 examination revealed any objective findings consistent with a history of chronic recurrent skin lesions, blisters, lesions or cellulitis consistent with stasis pigmentation, eczema, or ulceration caused by the service-connected idiopathic lymphedema as the Veteran asserts. 3. Entitlement to a TDIU is remanded. The TDIU issue was raised by the Veteran in the January 2014 NOD as part of the increased rating claims for idiopathic lymphedema. Rice v. Shinseki, 22 Vet. App. 447 (2009). As the increased rating claims are being remanded for further development, the Board will defer adjudication of the intertwined issue of entitlement to a TDIU. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Further, additional development is required. The appeal period for TDIU mirrors the period on appeal for the increased rating claims, which begins on October 13, 2011, one year prior to receipt of the claim for increase. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). Clarification is needed regarding the VA Form 21-8940 received in December 2019. On page 3 of this form, the Veteran appeared to indicate that she was unemployed from October 2012 to October 2014 due to her service-connected idiopathic lymphedema. However, on page 1, she indicated that her income received for the years 2012-2013 was $98,000.00 as a training specialist. On remand, the Veteran should clarify her periods of unemployment and employment from October 2011 to October 2014. Further, the Veteran noted in the January 2014 NOD that she had to change her profession in 2012 due to her idiopathic lymphedema. The clarification from the Veteran should include identification of all employers for the period of October 2011 to October 2014 such that VA Form 21-4192’s from those employers may be obtained. The matters are REMANDED for the following action: 1. Return the file and a copy of the remand to the January 2020 VA examiner, or another appropriate clinician if that examiner is unavailable, for an addendum. The examiner is asked to review the January 2014 NOD wherein the Veteran describes specific symptoms (i.e. broken skin and painful fissures between the toes; repeated bouts of cellulitis; blisters and lesions on the soles of her feet; and advanced stages of cellulitis; cellulitis affecting her arm pit, groin areas, intense sunburn, swelling in the arms and fingers) she believes are related to her service-connected idiopathic lymphedema. a) The examiner is asked to clarify whether the in-person clinical evaluation of the Veteran at the January 2020 examination revealed: (i) any current clinical findings suggestive of, or consistent with evidence of the skin symptoms described in the January 2014 NOD; or, (ii) a history of (since October 2011) recurrent skin lesions, sunburn, blisters, lesions or cellulitis as described in the January 2014 NOD- consistent with stasis pigmentation or eczema; intermittent ulceration; or persistent ulceration related to the service-connected idiopathic lymphedema. b) The examiner is also asked to clarify whether the lower extremity swelling noted over the duration of the appeal (i.e. since October 2011) is best described as either: (i) intermittent edema of extremity or aching and fatigue in leg after prolonged standing or walking, with symptoms relieved by elevation of extremity or compression hosiery; or, (ii) persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema; or, (iii) persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration; or, (iv) persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration; or (v) massive board-like edema with constant pain at rest If an in-person examination is necessary to address any of the questions posed, then one should be scheduled if feasible. 2. Ask the Veteran to complete another VA Form 21-8940 and/or provide clarification regarding her complete includes employment history specifically for the period from October 2011 to October 2014. Then, make attempts to obtain a completed VA Form 21-4192(s), Request for Employment Information, from all employers identified for this period. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Jake Choi, 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.