Citation Nr: 21002205 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 17-03 007 DATE: January 13, 2021 REMANDED Entitlement to service connection for heart to include, valvular heart disease and coronary artery disease due to herbicide exposure is remanded. Entitlement to service connection for peripheral neuropathy, right upper extremity is remanded. Entitlement to service connection for peripheral neuropathy, left upper extremity is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1966 to January 1968, including service in the Republic of Vietnam. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a April 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In April 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge. However, VA was unable to produce a complete transcript of the proceeding due to the audio malfunctions heard throughout the Veteran’s testimony in VA’s digital audio recording system (DARS). The Veteran was offered another hearing, however the Veteran responded in November 2020, that he did not wish to appear at another hearing. The Veteran was then given the opportunity to have his representative submit an IHP, which was received in January 2021. 1. Entitlement to service connection for heart condition to include, valvular heart disease and coronary artery disease due to herbicide exposure is remanded. The Veteran contends that his heart condition to include valvular heart disease and coronary artery disease is due to herbicide exposure (Agent Orange) from his service in Vietnam. The Veteran contends that the December 2019 examiner is an APRN and is not competent to provide a nexus opinion and requests the APRN’s credentials and an opinion by a cardiologist. The Veteran’s service treatment records are silent for any complaints, treatment, or diagnoses related to his heart condition. In January 2021, the Veteran’s representative challenged the competency and qualifications of the VA examiner that provided the December 10, 2019, medical opinion. The Veteran’s representative requested the curriculum vitae (CVs), the number of medical opinions this examiner has provided for the VA, and a list of any research or articles published by this examiner. The representative’s requests must be addressed. See Nohr v. McDonald, 27 Vet. App. 124 (2014). If the information requested is not available, then the AOJ should advise the Veteran and his representative of such and note the reasons for such in the record. In February 2015, the Veteran’s private treatment provider opined that the Veteran’s exposure to Agent Orange has directly caused all of the Veteran’s medical problems including pulmonary inflammation, and severe upper and lower neuropathy. The private treatment provider did not provide a rationale. In March 2016, the Veteran’s private treatment provider opined that the Veteran’s current heart conditions are directly related to his service in Vietnam. The doctor indicated that the Veteran’s symptoms include shortness of breath with any walking and is only able to walk 30 feet without becoming short of breath. The private treatment provider did not provide a rationale. In August 2019, the Veteran’s private treatment provider indicated that he has treated the Veteran for the past year. The doctor stated that the Veteran has known coronary artery disease “with an inferolateral wall MI on recent Cardiolite stress testing and recommended treatment consisting of Jardiance, which will help control his diabetes and present further cardiovascular events, strokes and death by up to 30 percent.” In December 2019, the Veteran underwent an examination for his heart condition. The examiner noted that the Veteran has a diagnosis of congestive heart failure, valvular heart disease, and heart valve replacement. The examiner also notes a letter from the Veteran’s primary care provider that reported a diagnosis of coronary artery disease (CAD) based on a Lexiscan study. The examiner stated that in August 2019 that a Lexiscan study was performed and that cardiology believed it to be nonischemic. The examiner noted that in 2016, the Veteran had a left heart catherization that resulted in normal coronary arteries and an absence of plaquing. The examiner stated, “the veterans primary care provider has diagnosed coronary artery disease in error, based on these clinical findings and facts.” Later in December 2019, VA obtained an addendum opinion for the Veteran’s heart condition. The examiner noted that the Veteran reported that in March 2016, he was diagnosed with congestive heart failure secondary to his aortic valve stenosis and had an aortic valve replacement. The examiner opined that the Veteran’s long-standing aortic valve stenosis is as likely as not caused his congestive heart failure; or resulted in “mild left ventricular hypertrophy and mild left atrial dilatation is seen on echocardiogram of 12/9/2019.” In summary, while VA obtained a medical opinion to address the Veteran’s heart condition, there are conflicting opinions. However, the Veteran’s private providers fail to provide a rationale and the Veteran challenges the competency of the VA medical opinions because the examiner was not a cardiologist. Thus, a remand is necessary to reconcile the Veteran’s contentions. 2. Entitlement to service connection for peripheral neuropathy, right upper extremity is remanded. 3. Entitlement to service connection for peripheral neuropathy, left upper extremity is remanded. The Veteran contends that his bilateral upper peripheral neuropathy is due to herbicide exposure, to include Agent Orange, from his service in Vietnam. The Veteran’s service treatment records are silent for any complaints, treatment, or diagnoses related to peripheral neuropathy. In an October 2014 EMG consult response note, the examiner stated that the Veteran had a normal exam of the “left upper extremity without electrodiagnostic evidence of peripheral neuropathy, plexopathy or radiculopathy.” The Veteran’s right extremity was not tested as “symptoms were symmetrical, and the left upper extremity was normal.” In the December 2014, VA medical opinion, the examiner opined, that there is no objective clinical evidence of record to substantiate a diagnosis of diabetic peripheral neuropathy of the upper extremities. As to the rationale the examiner cited the October 2014 EMG that stated, “normal exam of the left upper extremity without electrodiagnostic evidence of peripheral neuropathy, plexopathy or radiculopathy. Note-the right upper extremity was not tested as symptoms were symmetrical and the left upper extremity was normal.” In April 2015, the Veteran underwent a VA examination for his peripheral neuropathy condition. The Veteran reported an altered sensation in his hands and arms that started three years ago. The examiner noted that the Veteran had mild bilateral paresthesias and/or dysesthesias in his upper extremities. The Veteran had 3/5 strength in his right elbow flexion, elbow extension, wrist flexion, wrist extension, grip, and pinch (thumb to index finger). The Veteran had 4/5 strength in each of these categories for his left upper extremities. The examiner stated that the Veteran did not have upper extremity diabetic peripheral neuropathy. In March 2015, the Veteran’s private treatment provider submitted a letter on the Veteran’s behalf stating that the Veteran suffers from severe upper and lower extremity neuropathy. The doctor states that he believes his “neuropathy is caused by excessive exposure to Agent Orange, a nerve agent.” The doctor does not provide a rationale. In December 2016, the Veteran’s private treatment provider submitted a letter on the Veteran’s behalf indicating that the Veteran’s peripheral neuropathy pain in his upper and lower extremities has worsened. There is a conflict between the December 2016 VA examiner’s opinion that states that the Veteran does not have a diagnosis of peripheral neuropathy and the private treatment provider indicating that the Veteran has a diagnosis. In addition, the Veteran’s strength in his right upper extremities is weaker than the left, but the examiner did not test the Veteran’s right extremities. The Veteran also has service connection for diabetes, and the medical opinion is based on the presumption that the Veteran does not have an upper peripheral neuropathy diagnosis. The Board cannot make a fully informed decision on the issue of the Veteran’s bilateral upper peripheral neuropathy condition because no VA examiner has diagnosed the Veteran with bilateral upper peripheral neuropathy. Therefore, the claim must be remanded in order to schedule the Veteran for a VA examination to determine the etiology of his bilateral upper peripheral neuropathy condition, and obtain medical opinions determining the relationship between the Veteran’s condition and herbicide exposure, and the Veteran’s service connected diabetes condition. The matter is REMANDED for the following action: 1. In regard to the examiner that conducted the December 2019 examination for the Veteran’s heart condition, request a resume and/or CV, the number of medical opinions this examiner has provided for the VA, and a list of any research or articles published by this examiner. Upon receipt of the resume and/or CV, associate them with the record and provide the Veteran and his representative copies thereof for review. If any of the requested documents or information is not obtainable, the Veteran and his representative should be so advised and the reasons for such should be noted in the record. 2. After completing the above development, schedule the Veteran for a VA examination to assess his claim of entitlement to service connection for coronary artery disease. A complete copy of the claims file must be made available to the examiner, which must be a cardiologist. The examiner must consider the Veteran’s lay reports of observable symptomatology. The examiner must also take a history regarding the symptoms from the Veteran. After a thorough review of the medical and lay evidence of record, the examiner should address the following: (a.) List any and all heart conditions with which the Veteran is presently diagnosed, including whether he has a present diagnosis of any type of ischemic heart disease to include CAD. The examiner should also comment on whether medical records or service treatment records document any diagnosis of CAD. (b.) If the Veteran has a diagnosis of ischemic heart disease/CAD, determine whether the Veteran’s heart conditions including but not limited to congestive heart failure, valvular heart disease, heart valve replacement are at least as likely as not (50 percent or greater probability) (1) proximately due to his ischemic heart disease/CAD condition (2) aggravated beyond its natural progression by his ischemic heart disease/CAD condition. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his bilateral upper peripheral neuropathy condition. (a.) The examiner must opine whether it is at least as likely as not (50 percent or greater probability) that the bilateral upper peripheral neuropathy is related to an in-service injury, event, or disease, including exposure to Agent Orange. (b.) If not, the clinician should also provide an opinion as to whether it is at least as likely as not that the Veteran’s bilateral upper peripheral neuropathy is (1) proximately due to, or (2) aggravated beyond its natural progression by the Veteran’s service-connected diabetes. (c.) The examiner must provide the underlying reasons for any opinions provided. If the examiner is unable to provide this opinion without resorting to speculation, he or she must indicate why this is so. If aggravation is shown, the examiner should quantify the degree of aggravation, if possible. The question of secondary aggravation must be addressed separately from the question of secondary causation. The examiner must note that an opinion to the effect that one disability is not “caused by,” “a result of,” or “secondary to” another disability does not answer the question of aggravation and will necessitate a further opinion. 4. A complete rationale must be provided for all opinions offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. If the examiner finds that he/she cannot provide an opinion without resorting to speculation, he/she should explain the inability to provide an opinion and identify precisely what facts could not be determined. He/she should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). The AOJ should ensure that any additional evidentiary development suggested by the examiner be undertaken so that a definite opinion can be obtained. (Continued on the next page)   5. Thereafter, readjudicate the claim. If the benefits sought on appeal remain denied, issue a supplemental statement of the case to the Veteran and his representative. Then return the appeal to the Board for further appellate review. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Quist, 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.