Citation Nr: 21002105 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 191212-49444 DATE: January 12, 2021 REMANDED Entitlement to service connection for impeded circulation in the right leg, also claimed as numbness, weakness and pain in the right leg, to include as secondary to service-connected scar, distal right tibia is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1951 to March 1955. In August 2019, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of a July 2019 rating decision. In September 2019, the Agency of Original Jurisdiction (AOJ) issued the HLR decision on appeal, which considered the evidence of record at the time of the initial rating decision. In the December 2019 VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected the Direct Review docket. In a January 2020 decision, the Board denied the Veteran’s claim for service connection. The Veteran appealed the Board’s decision and in a September 2020 Order, the United States Court of Appeals for Veterans Claims (Court) endorsed a September 2020 joint motion for remand (JMR), vacated the Board’s decision to the extent it denied the claim for service connection, and remanded the case for further action consistent with the terms of the JMR. Entitlement to service connection for impeded circulation in the right leg, also claimed as numbness, weakness and pain in the right leg, to include as secondary to service-connected scar, distal right tibia is remanded. The Board regrets additional delay, but a remand is necessary to obtain a new medical examination, if necessary, and a medical opinion due to the inadequacy of the June 2019 VA Peripheral Nerves Conditions (not including Diabetic Sensory-Motor Peripheral Neuropathy) Disability Benefits Questionnaire. The September 2020 JMR states that the Board erred in relying on the examiner’s inadequate conclusion that the Veteran’s claimed numbness, weakness and pain in the right leg were caused by his severe L3-S1 spinal stenosis with radiculopathy. In particular, the JMR provides that the conclusion is inadequate because the examiner failed to properly consider the relationship between the Veteran’s claimed right leg disability and his service-connected scar, distal right tibia, to include whether that scar aggravated his right leg pain, numbness, and weakness. The JMR also indicates that while the examiner noted that the Veteran did not have any scars on the June 2019 examination report, he did not reconcile this observation with the finding in the June 2019 medical opinion that the Veteran had a 5-inch superficial laceration of the right leg and that he is service-connected for a scar on the distal right tibia. As such, the JMR provided that a remand is warranted for a new examination or medical opinion that determines whether the Veteran has a scar, and if so, whether it aggravates his right leg condition The matter is REMANDED for the following action: 1. Obtain a medical opinion from an appropriate examiner concerning the etiology of the Veteran’s right leg disability, claimed as numbness, weakness and pain in the right leg. The Veteran should not be scheduled for an examination unless deemed necessary by the examiner rendering an opinion on this claim. If the clinician determines that an additional physical examination of the Veteran is required, schedule such an examination or telehealth interview, review of the record, etc. if an in-person examination is not feasible. The examiner must review the Veteran’s claims folder. The examiner must: (a.) Identify all scars found to be present on the Veteran’s right leg. In making the above determination, the examiner should consider: • An August 1953 medical note indicating that the Veteran jumped from a table accidently striking his leg against the edge of the table and as a result has a 5-inch laceration on anterior aspect of his right leg, that there was no artery or nerve involvement, and that the wound was cleaned and sutured. • The December 2018 Artery and Vein Conditions (Vascular Diseases Including Varicose Veins) Disability Benefits Questionnaire that indicates that the Veteran has a right lower tibia scar that measures 8 centimeters in length by 0.5 centimeters in width, described as very well-healed, stable, and superficial. • The Veteran is service-connected for scar, distal right tibia. (b.) Opine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s right leg disability (claimed as numbness, weakness and pain in the right leg) was proximately due to his service-connected scar, distal right tibia. (c.) Opine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s right leg disability (claimed as numbness, weakness and pain in the right leg) was aggravated, i.e., worsened beyond its natural progression, by his service-connected scar, distal right tibia. A complete rationale must be provided for all opinions and conclusions reached. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sean Mussey, 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.