Citation Nr: 21062746 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 16-36 383 DATE: October 12, 2021 REMANDED Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a bilateral upper extremity neuropathy disability is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. REFERRED The issue of entitlement to service connection for an acquired psychiatric disorder was raised in January 2016 correspondence and is referred to the Agency of Original Jurisdiction (AOJ) for adjudication. REASONS FOR REMAND The Veteran served on active duty in the U.S. Air Force from October 1990 to April 1996 as a vehicle mechanic. This appeal comes before the Board of Veterans' Appeals (Board) from an October 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans' Law Judge at a July 2019 Board videoconference hearing. A transcript of the hearing has been associated with the claims file. The claims were previously before the Board in December 2019. A September 2020 order of the United States Court of Appeals for Veterans Claims (Court) implemented a September 2020 Joint Motion for Partial Remand (JMPR), vacating and remanding, in part, the December 2019 Board decision that denied entitlement to service connection for a lumbar spine disability and entitlement to service connection for bilateral upper extremity peripheral neuropathy. As such the issues of entitlement to service connection for a lumbar spine disability and service connection for bilateral upper extremity peripheral neuropathy are again before the Board. In March 2021, the Board remanded these issues to the RO for additional development. Following the Board remand, in March 2021 correspondence the AOJ attempted to obtain the Veteran's earlier private treatment records and associate them with the claims file. The Veteran responded and stated that he did not have any additional private records to submit. The Board notes that the original appeal included a service connection claim for a deviated septum. In a May 2021 rating decision, the Veteran was granted service connection for a deviated septum. The decision is considered a full grant of benefits. Ab v. Brown, 6 Vet. App. 35 (1993). Therefore, that issue is no longer in appellate status. 1. Entitlement to service connection for a back disability The Veteran contends that he is entitled to service connection for a back disability because he injured his back several times in service. Service treatment records (STRs) show that the Veteran sought treatment for low back pain in December 1990 following a 12-mile road march carrying a 90-pound pack. A clinician prescribed warm baths and anti-inflammatory and muscle relaxant medication. There was no follow-up and no other treatment encounters for low back pain. In a discharge physical examination in April 1996, the Veteran reported back pain that resolved by 1994. He explained that he treated the back pain with over-the-counter medication and was "presently asymptomatic." He said the back pain was due to heavy lifting, and he denied back pain at his separation exam. The examiner noted no spinal abnormalities. During December 2014 VA treatment, the Veteran noted he experienced chronic back pain in service. He told the treating physician that he had back pain for the past 15 years. He also said his pain sometimes resulted in tingling and numbness in the lower extremities. He declined medication and x-rays. During February 2015 VA treatment for back pain, the Veteran reported that he had been "disabled for 7 years." The statement made during the February 2015 VA treatment implies that the Veteran may be in receipt of Social Security Administration disability benefits. No records from the Social Security Administration have been associated with the claim file, and no evidence of an attempt to obtain such records exists in the claim file. In light of this, the record appears to be incomplete, and such evidence may support the Veteran's claim. Furthermore, the Board acknowledges that these records are with a Federal facility and that VA has an increased obligation in regard to obtaining records in the custody of a Federal department or agency. 38 C.F.R. § 3.159(c)(2). 2. Entitlement to service connection for bilateral upper extremity peripheral neuropathy The Veteran contends that he is entitled to service connection for an upper extremity neuropathy disability. STRs reveal that the Veteran sought treatment for hand numbness, wrist pain, and upper extremity cramping in February 1994. He was assessed with carpal tunnel syndrome and was provided wrist splints. He was scheduled for occupational therapy, but he did not attend those appointments. At discharge, while the Veteran reported periodic leg cramping, he denied any issues with his upper extremities, and an examiner noted no upper extremity abnormalities. During December 2014 VA treatment, the Veteran complained of bilateral shoulder and hand pain. He reported this pain began while serving in the military. In February 2015, a clinician noted that he had myofascial tension-type joint pain and was scheduled for an electromyogram (EMG) with his private doctor. As explained above, an attempt to obtain the private treatment by the RO was unsuccessful, because the Veteran failed to submit the medical release form. See April 2021 correspondence. In a January 2016 email, the Veteran said that he experienced arm and hand numbness. His ex-wife corroborated this. His current wife noted that he will just drop things that he is holding due to the pain and numbness in his arms and hands. At the July 2019 Board hearing, the Veteran testified that he did see a doctor in service, but all the information was unreported. He received "braces" to sleep with and help eliminate the pain, but they did not work. He testified that his arms mostly went numb and tingled when he raised them over his head, and that he could no longer drive. The Veteran attended a VA examination in February 2020. He reported intermittent numbness and tingling in his fingers and hands since his time on active duty. EMG studies were performed on his upper extremities and the results were normal. A VA opinion was obtained in May 2021. The examiner determined that the Veteran's neuropathic upper extremity symptoms were less likely than not related to his service, to include the 1994 treatment for carpal tunnel syndrome. The examiner explained that the 1994 carpal tunnel syndrome diagnosis was provisional and never confirmed. He went on to explain that while the Veteran's current neuropathic upper extremity symptoms were of unknown etiology, they were less likely than not related to the in-service treatment for wrist pain, numbness, and cramping. He explained that those in-service symptoms were "not known to produce the Veteran's current upper extremity symptoms." While the Veteran may only have had a provisional diagnosis of carpal tunnel syndrome in service, he did seek treatment for symptoms that mirror what he currently reports. The VA examiner did not provide any rationale as to why the symptoms the Veteran had in service are not related to his current symptoms. The Board finds an additional VA opinion is necessary prior to adjudication. 3. Entitlement to total disability based on individual unemployability (TDIU) due to service-connected disabilities Finally, because a decision on the remanded issues of entitlement to service connection for a back disability and an upper extremity neuropathy disability could significantly impact a decision on the issue of entitlement to a TDIU rating, the issues are inextricably intertwined, and a remand of the claims is required. Although the Veteran testified at the hearing that he had not worked since 2007. In some records or statements in 2015, the Veteran reported that he had not worked in 7-8 years. In private chiropractic records from 2013 to 2015, the clinician noted that the Veteran was employed or self-employed. A request to the Veteran for his complete current employment history including in self-employment or business ownership situations is necessary. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment and associate them with the claims file. 2. Contact the Social Security Administration and request all pertinent documentation pertaining to any claim for disability benefits by the Veteran including any medical records that Social Security has regarding the Veteran. These records should be associated with the claim file. All efforts to obtain the records should be associated with the claim file. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's upper extremity neuropathy disability is at least as likely as not caused by service, to include the February 1994 treatment for carpal tunnel syndrome. Review of the entire claims file is required. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. Request from the Veteran a current listing of all employment in the past 10 years including self-employment or business ownerships. 5. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issue of entitlement to a TDIU rating. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Fitzgerald, 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.