Citation Nr: 21063017 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 09-46 055 DATE: October 12, 2021 ORDER Entitlement to an initial 20 percent rating, but no higher, for left lower extremity peripheral neuropathy is granted. Entitlement to service connection for chronic obstructive pulmonary disease (COPD) is denied. REMANDED Entitlement to service connection for an acquire psychiatric disorder is remanded. Entitlement to service connection for ischemic heart disease is remanded. Entitlement to service connection for bilateral upper extremity carpal tunnel syndrome, to include as secondary to service connected diabetes mellitus type II, is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's left lower extremity peripheral neuropathy manifested by, at worst, moderate incomplete paralysis and did not manifest in moderately severe incomplete paralysis, the loss of reflexes, muscle atrophy or constant pain. 2. The Veteran's COPD did not begin during active service and is not otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for an initial 20 percent rating, but not higher, for left lower extremity peripheral neuropathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1 4.14, 4.123, 4.124a, Diagnostic Code 8520. 2. The criteria for service connection for COPD, to include as secondary to service-connected chronic bronchial asthma, have not been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1967 to January 1970, to include service in the Republic of Vietnam. These matters come to the Board of Veterans' Appeals (Board) on appeal from January 2008 and March 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) Detroit, Michigan. This case was most recently before the Board in July 2017 and July 2019, at which time the appeals were remanded to the Agency of Original Jurisdiction (AOJ) for further development. Specifically, the matters were remanded to obtain updated VA treatment records, to obtain private treatment records, to obtain an etiology opinion with regards to the Veteran's claimed COPD and to obtain an examination to determine the current nature and severity of the Veteran's left lower extremity peripheral neuropathy. Updated VA treatment records have been associated with the record and a June 2020 notification letter informed the Veteran that a recently submitted Authorization to Disclose Information to VA (VA Form 21-4142) was completed incorrectly. An October 2020 informed the Veteran that he could complete a VA Form 21-4142 to allow VA to obtain medical records on his behalf. A VA etiology opinion as to the claim for service connection for COPD was received in October 2020. The Board therefore determines that there has been substantial compliance with its previous remands with regards to the claims decided herein. The case has now been returned to the Board for appellate action. The instant appeal was docketed at the Board in March 2021. In March 2021, the Veteran's attorney requested the full 90 days following docketing to submit additional evidence and argument. A May 2021 letter from the Veteran's attorney repeated this request. This requested time period has now expired. It is worth noting that in the July 2019 decision, the Board granted an earlier effective date of January 8, 2010, for the award of service connection for left lower extremity peripheral neuropathy and also remanded the Veteran's claim for an increased rating. By a March 2021 correspondence, the Veteran's attorney stated "[the March 2020 rating] decision granted entitlement to an earlier effective date for the date of service connection for the left lower extremity peripheral neuropathy which remains on appeal in the Legacy system at a higher level of adjudication and is thus not at issue here." However, this is incorrect. The earlier effective date claim has already been adjudicated and is therefore not currently before the Board. Increased Rating Left Lower Extremity Peripheral Neuropathy The Veteran, by advancing his appeal, contends that a higher rating is warranted for his left lower extremity peripheral neuropathy. Specific argument in support of this appeal has not been provided. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. It is permissible to switch diagnostic codes to reflect more accurately a claimant's current symptoms. See Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran's claim. The Veteran's left lower extremity peripheral neuropathy is currently rated as 10 percent disabling under Diagnostic Code 8520. 38 C.F.R. § 4.124a. Under Diagnostic Code 8520, a 10 percent rating is assigned for mild incomplete paralysis of the sciatic nerve, a 20 percent rating is assigned for moderate incomplete paralysis, a 40 percent rating is assigned for moderately severe incomplete paralysis, and a 60 percent rating is assigned for severe incomplete paralysis with marked muscular atrophy. Id. An 80 percent rating is assigned for complete paralysis, where the foot dangles and drops, there is no active movement possible of the muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. Id. The term "incomplete paralysis" with peripheral nerve injuries indicates a degree of loss or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to the varied level of the nerve lesion or to partial regeneration. The words "mild," "moderate," and "severe" are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Mild is generally defined as "not being or involving what is extreme" or "not severe." Merriam-Webster's Collegiate Dictionary, 787 (11th ed. 2003). Moderate is generally defined as "tending toward the mean or average amount." Id. at 798. Severe is generally defined as "of a great degree" or "serious." Id. at 1140. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. See Note at "Diseases of the Peripheral Nerves" in 38 C.F.R. § 4.124(a). In rating peripheral nerve disability, neuritis-characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating-is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.123. When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Turning to the evidence, at an August 2011 VA examination, the Veteran reported tingling and numbness in his left lower extremity that had gradually increased in intensity. He took medication, responded fairly to treatments, and had no side effects from the treatments. He denied a history of hospitalization or surgery, balance or coordination problems, mobility problems, or other current symptoms. On physical examination, the Veteran's detailed reflex examination findings were all normal. Sensory examination results of the left lower extremity showed normal vibration, decreased pain or pinprick, normal position sense, decreased light touch, and no dysesthesias. Detailed motor examination results were all normal. Muscle tone was normal. The Veteran did not have muscle atrophy, gait abnormality, imbalance, tremor, evidence of fasciculation, nor was any joint affected by his nerve disorder. The examiner stated that the Veteran's left lower extremity peripheral neuropathy presented with tingling and numbness, nerve dysfunction, and neuralgia. There was no evidence of paralysis or neuritis. It did not impact the Veteran's occupation or daily activities. At a May 2016 VA examination, in pertinent part, the Veteran reported that beginning in 1995, he noticed burning of his feet and low back pain shooting down both of his legs to his feet. Symptoms attributable to his left lower extremity peripheral neuropathy included moderate constant pain; no intermittent pain; moderate paresthesias and/or dysesthesias; and moderate numbness. On physical examination, muscle strength testing was normal with no muscle atrophy demonstrated. Reflex examination was normal. Sensory examination showed decreased sensation testing for light touch in the upper anterior thigh, thigh or knee, lower leg or ankle, and foot or toes. The Veteran did not have trophic changes attributable to his peripheral neuropathy. His gait was abnormal and described as slow and deliberate. Phalen's sign and Tinel's sign were negative. The May 2016 VA examiner determined the Veteran had moderate incomplete paralysis of the sciatic nerve, moderate incomplete paralysis of the external popliteal nerve and moderate incomplete paralysis of musculocutaneous nerve. The Veteran endorsed the occasional use of a cane and the constant use of a walker as a normal mode of locomotion. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. The examiner noted the Veteran's left lower extremity peripheral neuropathy impacted his ability to work due to inability to drive, and the Veteran could not stand or walk for prolonged periods. On VA examination in August 2017, the Veteran reported he had leg and feet numbness, that his medication no longer helped, and that his feet tingled with intermittent numbness. Symptoms attributable to his left lower extremity peripheral neuropathy included mild intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness. Neurological examination was normal. Deep tendon reflex examination results were all normal. Light touch/monofilament testing results were decreased in the foot/toes. Position sense testing was normal. Vibration sensation testing results were decreased. Cold sensation testing results were normal. The Veteran did not have muscle atrophy or any trophic changes attributable to diabetic peripheral neuropathy. The examiner determined the Veteran had mild incomplete paralysis of the left lower extremity. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The examiner noted the Veteran's left lower extremity peripheral neuropathy did not impact his ability to work. Phalen's sign and Tinel's sign were both negative. On VA examination in May 2018, the Veteran reported tingling in his foot, weakness in the extremity, and left big toe was swollen. He denied any medications. Symptoms attributable to his left lower extremity peripheral neuropathy included mild intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness. Muscle strength testing was normal. The Veteran did not have muscle atrophy. Reflex examination was normal. Sensory examination showed decreased sensation to light touch in the foot/toes. The Veteran did not have trophic changes attributable to peripheral neuropathy. His gait was normal. Phalen's signa and Tinel's sign were negative. The May 2018 VA examiner determined the Veteran had mild incomplete paralysis of the sciatic nerve. The Veteran endorsed the regular use of a cane as a normal mode of locomotion. Functioning was not so diminished that he was equally well served by amputation with prosthesis. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The examiner noted the Veteran's left lower extremity peripheral neuropathy did not impact his ability to work. Further review of the record shows that the Veteran received treatment at the VA medical center and from private treatment providers for various disabilities, to include his left lower extremity neuropathy. However, there is no indication from the treatment notes of record that the Veteran has reported symptoms of neuropathy that are worse than those noted in the various VA examination reports and treatment records of record. Based on the foregoing, the Board finds that an initial rating of 20 percent, but no higher, for left lower extremity peripheral neuropathy is warranted throughout the period on appeal. Neurological findings at the August 2011 VA examination showed the Veteran did not have paralysis of the sciatic nerve and had, at worst, tingling, numbness, nerve dysfunction, neuralgia, and decreased sensation. Additionally, neurological findings at the August 2017 and May 2018 VA examinations showed the Veteran had mild incomplete paralysis in the left lower extremity. The Veteran has been shown to have normal motor strength, no evidence of muscle atrophy, with some decreased sensation in the foot, numbness, tingling, and pain. The Veteran denied symptoms that affected his activities of daily living, recreation, or employment and denied any flare-ups of the left lower extremity. Neurological findings at his May 2016 VA examination showed the Veteran had moderate incomplete paralysis of the sciatic, external popliteal, and musculocutaneous nerves. Therefore, the Board finds that the symptoms attributable to the Veteran's left lower extremity due to his sciatic nerve peripheral neuropathy most closely approximate moderate incomplete paralysis. Accordingly, an initial rating of 20 percent, but no higher, for left lower extremity peripheral neuropathy is warranted. An initial rating in excess of 20 percent for left lower extremity peripheral neuropathy is not warranted at any time during the period on appeal. The record does not establish, and the Veteran has not alleged, the loss of reflexes, muscle atrophy or constant pain. As noted above, the neurological findings are described above, and the examiners found that the Veteran's sciatic nerve neuropathy has manifested by, at worst, moderate incomplete paralysis of the left sciatic nerve. At no time has the Veteran demonstrated left lower extremity peripheral neuropathy that was manifested by moderately severe incomplete paralysis sciatic nerve. The Board finds that the symptoms attributable to the Veteran's left lower extremity due to his sciatic nerve peripheral neuropathy most closely approximate moderate incomplete paralysis. The Board acknowledges the Veteran's statements that his left lower extremity peripheral neuropathy is more severe than evaluated. He is competent to report his symptoms and has presented credible statements in this regard. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Indeed, the various VA examination reports of record are largely based on the Veteran's own statements. The Board finds, however, that neither the Veteran's statements nor medical evidence demonstrates that the criteria for a higher rating have been met during any period on appeal. The Board also acknowledges that the Veteran's VA treatment records note complaints of and treatment for his sciatic peripheral neuropathy. However, these records do not address the specific rating criteria necessary to determine severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment as the examiner had the opportunity to inquire with the Veteran as to his symptoms, consider the entire evidence of record, and perform objective testing. The Board has considered whether a staged rating under Hart, supra, is appropriate for the Veteran's service connected left lower extremity peripheral neuropathy. However, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning further staged rating for such disabilities is not warranted. Further, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). Accordingly, the Board finds that an initial compensable rating of 20 percent, but no higher, for left lower extremity peripheral neuropathy is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service Connection - COPD The Veteran asserts that he has COPD that is as a result of his active service. Specifically, he contends that his COPD is as a result of exposure to herbicide agents during his service in the Republic of Vietnam. See VA Form 21-0820 Report of General Information, March 30, 2011. Additionally, the record reflects the Veteran's COPD may be as secondary to his service-connected asthma. See July 2004 VA examination report. The Board notes that service connection is already in effect for chronic bronchial asthma. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Relevant laws and regulations provide that absent affirmative evidence to the contrary, there is a presumption of exposure to herbicides agents (to include Agent Orange) for all Veterans who served in Vietnam during the Vietnam Era. 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). In the instant case, the Veteran's service personnel records reflect service in the Republic of Vietnam. Therefore, he is presumed to have been exposed to herbicide agents coincident with such service. If a veteran was exposed to an herbicide agents, such as Agent Orange, during active service, service connection will be presumed for certain diseases, including ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease), if they become manifest to a degree of 10 percent or more at any time after service. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309(e). However, COPD is not one of those diseases for which service connection will be presumed. Notwithstanding the presumption, service connection for a disability claimed as due to exposure to herbicides may be established by showing that a disorder resulting in disability or death was in fact causally linked to such exposure. See Combee v. Brown, 34 F.3d 1039, 1044 (Fed. Cir. 1994), citing 38 U.S.C. § 1113(b) and 1116 and 38 C.F.R. § 3.303. Turning to the evidence of record, service treatment records are silent for complaints of, treatment for, or diagnosis of a lung condition, to include COPD. Post-service treatment records include an August 2009, a VA medical opinion was obtained to determine whether the Veteran's currently breathing condition was due to asthma or COPD. The VA examiner opined that the Veteran had a recent PFT that did not show any obstructive impairment, and there was no clinical or PFT evidence of COPD. Therefore, the examiner found the Veteran's breathing condition was solely due to his asthma. October 2005 and January 2006 VA treatment records indicated the Veteran had a diagnosis of COPD per a January 2004 PFT showing "mild obstructive impairment with no significant response to bronchodilator." The Veteran was afforded a VA examination for respiratory conditions in April 2013. At that time, the examiner diagnosed asthma. A diagnosis of COPD was not rendered. May 2013 and November 2016 VA treatment records, as well as a September 2016 private treatment record, indicated the Veteran had a diagnosis of COPD. Specifically, the November 2016 VA treatment record states the Veteran had COPD, not in exacerbation. With regards to direct service connection, a July 2004 VA respiratory examiner found that the Veteran had bronchial asthma since 1968, and the Veteran stated he had been diagnosed with emphysema (COPD) three to four years prior. The July 2004 examiner noted a January 2004 pulmonary function test (PFT) showed mild obstructive impairment with no significant response to a bronchodilator, and decreased diffusion possibly due to emphysema. The examiner diagnosed mild COPD, as likely as not related to tobacco use and chronic bronchial asthma. However, the July 2004 VA opinion did not provide any supporting rationale for the conclusions reached and provided a conclusory statement that his COPD was due to his tobacco use and asthma. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). This opinion is therefore afforded little, if any, probative weight. A September 2020 VA examiner diagnosed COPD and asthma and opined that the Veteran's COPD was less likely than not related to service. The examiner noted that the record showed that the Veteran had a chronic breathing problem due to exposure to agent orange and was diagnosed with asthma in 1986 before exiting service in 1970. The examiner also noted the Veteran had a history of smoking from 1973 to 2000, of about one quarter pack per day until he quit smoking in 2000 and that he had a diagnosis of COPD in January 2016. The examiner noted that the medical literature shows smoking is the leading cause of COPD, that smoking is also a trigger for COPD flare-ups and that smoking damages the air sacs, airways, and the lining of the lungs causing injured lungs to have trouble moving enough air in and out, making it hard to breathe. Additionally, the examiner noted that the medical literature states that most people with asthma will not develop COPD, and many people with COPD do not have asthma. Therefore, the examiner opined it was less likely as not that his COPD was related to service to include herbicide agent exposure and that his COPD was also not a maturation of his service-connected bronchial asthma. This opinion has clear conclusions and supporting data, as well as reasoned medical explanations when determining the Veteran's COPD is less likely than not related to service, herbicide agent exposure, nor a maturation of his bronchial asthma. Barr v. Nicholson, supra; Stefl v. Nicholson, supra; Nieves-Rodriguez v. Peake, supra. This opinion is therefore afforded great probative weight. There is no contrary opinion of record. The Board notes the Veteran's statements and contentions that his COPD was as a result of herbicide agent exposure during his service in the Republic of Vietnam. However, the contemporary evidence contradicts this assertion, and there are no medical findings of record related to COPD until 46 years after his period of service, despite numerous complaints and extensive treatment for his chronic bronchial asthma. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to" and a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's COPD and any instance of his service, or potential relationship to a service-connected disability, to be complex in nature. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Although the Veteran is competent to describe his current symptoms, such as shortness of breath, the Board accords his statements regarding the etiology of such a disorder little probative value as he is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). The question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and requires the administration and interpretation of diagnostic testing. In the instant case, there is no suggestion that the Veteran has had any medical training. Hence, the Board finds that he is not competent to provide a medical opinion to support this claim on the basis of his assertions alone. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the opinion of the Veteran is nonprobative evidence. The Board finds that the only probative medical evidence of record, the findings and September 2020 opinion of record, to be of greater probative value than the July 2004 opinion of record and the Veteran's lay contentions. Upon review of the evidence, the Board finds the preponderance of the evidence is against the claim. Consequently, service connection for such disorder is not warranted. As the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt doctrine is not applicable to this claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND 1. Service Connection Acquired Psychiatric Disorder The Veteran seeks service connection for an acquired psychiatric disorder. His attorney contends that his psychiatric disorder may have been caused or aggravated by his severe service-related impairments. See Correspondence, October 17, 2018. As noted above, the claim for entitlement to service connection for an acquired psychiatric disorder was most recently before the Board in July 2019, when the matter was remanded to the AOJ for further development. The Board directed the AOJ to afford the Veteran an additional VA examination for his claim as the previous April 2017 VA examination was inadequate to decide the claim because it did not provide an opinion as to whether a current psychiatric disorder was aggravated by his service-connected disabilities. The Board directed the examiner to provide opinions as to whether the Veteran's psychiatric disorder was at least as likely as not aggravated by his service-connected physical disabilities, to include prostate cancer, bronchial asthma, diabetes, left lower extremity peripheral neuropathy, post-inflammatory pigmentation, anemia, and prostatectomy surgical scar. Additionally, the Board directed the examiner provide a rationale for all opinions provided, and if the examiner found the current psychiatric disorder was aggravated to attempt to quantify the degree of aggravation beyond the baseline. The Veteran was afforded the directed VA examination in August 2020 and January 2021. In the August 2020 VA opinion, the examiner opined the Veteran's diagnosed acquired psychiatric disorder was at least as likely as not due to problems in interpersonal relationships, unemployment, unstable housing, chronic pain, and severe alcohol use; and was less likely than not aggravated by his physical disabilities to include prostate cancer, bronchial asthma, diabetes, left lower extremity peripheral neuropathy, post-inflammatory pigmentation, anemia, and prostatectomy surgical scar. Rather, the examiner opined that an acquired psychiatric disorder was at least as likely as not aggravated by alcohol use disorder. Then, in a January 2021 VA addendum opinion, the examiner opined the Veteran's acquired psychiatric disorder was less likely than not secondary to service-connected prostate cancer, bronchial asthma, diabetes, left lower extremity peripheral neuropathy, post-inflammatory pigmentation, anemia, and prostatectomy surgical scar. The examiner noted that the Veteran presented with a long history of psychiatric hospitalizations since the 1990s for alcohol intoxication and dependence and substance induced depression or mood disorder, and that his depression was related to unemployment, unstable housing, and chronic alcohol use. The examiner also found that a baseline level of severity could not be determined because the diagnosed depressive disorder was less likely than not aggravated by his service-connected physical disabilities, and was at least as likely as not that the depressive disorder was aggravated by alcohol use disorder. The examiner further noted that the acquired psychiatric disorder was not aggravated beyond its natural progression because there was no evidence of aggravation based on the most recent psychiatric note dated January 2021. The Board finds the August 2020 and January 2021 VA opinions incomplete to decide the claim. Neither examiner provided supporting rationale for the opinions rendered as directed by the July 2019 Board remand. Rather, the examiners merely provided conclusory opinions that the Veteran's psychiatric disorder was not aggravated by his service-connected conditions. Given these deficiencies, the Board is unable to find that substantial compliance with the prior remand has been achieved. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999). As such, remand is again required to afford the Veteran an additional VA examination that complies with the Board's prior remand directives. See Stegall v. West, 11 Vet. App. at 268, 271 (1998). 2. Service Connection Ischemic Heart Disease The Veteran seeks service connection for ischemic heart disease, to include as due to herbicide agent exposure. Specifically, the Veteran asserts that his cardiac disorder is ischemic heart disease and/or ischemic in nature, and presumptive to exposure to herbicide agents. See Third Party Correspondence, July 6, 2015. As noted above, the claim for entitlement to service connection for ischemic heart disease was most recently before the Board in July 2019, when the matter was remanded to the AOJ for further development. The Board directed the AOJ to afford the Veteran an additional VA examination as the previous VA examiner found that the Veteran did not have a diagnosis of ischemic heart disease but instead had nonischemic cardiomyopathy. However, the Veteran submitted September 216 private treatment records indicating a medical history of coronary atherosclerosis, and October 2016 and October 2017 VA treatment records showing a past medical history of coronary artery disease. Thus, the Board found another VA examination was necessary to reconcile the evidence and determine whether the Veteran had a diagnosis of ischemic heart disease. In its July 2019 remand directives, the Board directed the examiner to provide opinions as to whether the Veteran currently suffers from ischemic heart disease, and that the examiner's opinion should reflect consideration of September 2016 private treatment records, and October 2016 and October 2017 VA treatment records showing a medical history of coronary atherosclerosis and/or coronary artery disease. The Veteran was afforded VA examinations in October 2020 and November 2020. In the October 2020 VA opinion, the examiner found there was documentation of coronary artery disease in 2013, and that such condition was presumptive to his exposure to herbicide agents in the Republic of Vietnam. Then, in the November 2020 VA opinion, the examiner stated a diagnosis of ischemic heart disease could not be confirmed, and noted a urologist note of coronary artery disease that was not supported by test or VA cardiology notes through October 2019; and that no stress test had shown a diagnosis of ischemia, coronary atherosclerosis, or ischemic heart disease. The Board finds the October 2020 and November 2020 VA opinions incomplete to decide the claim. In this regard, neither examiner provided any reconciliation nor addressed the conflicting evidence of record, to include the September 2016 private treatment records and October 2016 and October 2017 VA treatment records. The October 2020 VA opinion found a diagnosis of coronary artery disease in 2013 but did not address the conflicting evidence indicating the Veteran had nonischemic heart disease, and the November 2020 VA opinion found there was no diagnosis of ischemic heart disease or coronary artery disease. Neither opinion provided supporting rationale for their determination of whether the Veteran has a qualifying heart disease presumptive for his exposure to herbicide agents as directed by the Board remand. Given these deficiencies, the Board is unable to find that substantial compliance with the prior remand has been achieved. See D'Aries v. Peake, supra; see also Dyment v. West, supra. As such, remand is again required to afford the Veteran an additional VA examination that complies with the Board's prior remand directives. See Stegall v. West, supra. 3. Service Connection Bilateral Upper Extremity Carpal Tunnel Syndrome The Veteran seeks service connection for bilateral upper extremity carpal tunnel syndrome as secondary to his diabetes mellitus. As noted above, the claim for entitlement to service connection for bilateral upper extremity carpal tunnel syndrome was most recently before the Board in July 2017, when the matter was remanded to the AOJ for further development. The Board directed the AOJ to afford the Veteran an additional VA examination as the October 2007 VA examiner acknowledged the Veteran's subjective complaints of tingling and numbness of the hands, but found no objective signs of neuropathy nor clinical evidence of carpal tunnel syndrome. However, the Board found the Veteran competent to report symptoms, to include numbness and tingling of his bilateral upper extremities, as such symptoms are certainly capable of lay observation. Moreover, the Board noted that the Veteran's clinical records reflected neurological diagnoses during the pendency of the claim. Therefore, the Board found that an opinion was not provided concerning the potential relationship between his symptomatology and diagnosed conditions and his diabetes mellitus. The Board directed the examiner to opine as to whether the Veteran's diagnosed nerve disorder affecting his bilateral upper extremities either had its clinical onset during active service, or was manifest within a year of service separation, or is related to any incident of service, to include herbicide exposure; and to opine whether the diagnosed nerve disorder of the bilateral upper extremities was caused by, or aggravated by, any of the Veteran's service-connected disabilities. The Veteran was afforded the directed VA examination in August 2017. At that time, the examiner found that the Veteran did not have peripheral neuropathy or a peripheral nerve condition as there was no clinical or objective evidence of bilateral carpal tunnel syndrome in the upper extremities. However, in an August 2017 VA examination report for peripheral neuropathy, the examiner noted the Veteran had mild numbness of the bilateral upper extremities but found the Veteran did not have upper extremity diabetic peripheral neuropathy. The examiner then opined that the Veteran's subjective symptoms of bilateral upper extremities neither had their clinical onset during active service nor was manifest within a year of service separation, nor were related to any incident in service, to include herbicide exposure. The examiner also opined that the Veteran's subjective symptoms of bilateral upper extremities were not caused by, nor aggravated by any of his service connected disabilities. In this regard, the examiner noted that, after a review of the service treatment records, review of the claims file and evidence, physical examination, and interview of the Veteran, his subjective symptoms were not incurred in nor related to active service; and that his service-connected disabilities were stable at that time. The Board finds the August 2017 VA opinions incomplete to decide the claim. In this regard, the examiner failed to adequately address the Veteran's lay statements and contentions regarding his subjective symptoms of bilateral upper extremity carpal tunnel syndrome. Additionally, the opinion provided failed to include supporting rationale for the conclusions reached as directed by the Board remand. Given these deficiencies, the Board is unable to find that substantial compliance with the prior remand has been achieved. See D'Aries, 22 Vet. App. at 105; see also Dyment v. West, supra. As such, remand is again required to afford the Veteran an additional VA examination that complies with the Board's prior remand directives. See Stegall v. West, supra. 4. Entitlement to a TDIU Regarding TDIU, the Board notes that the issue of entitlement to a TDIU is inextricably intertwined with the claims remanded herein. Harris v. Derwinski, 2 Vet. App. 180, 183 (1991). Hence, a determination on the claim for TDIU prior to November 12, 2016 should be deferred pending final dispositions of the claims of entitlement to service connection for acquired psychiatric disorder and ischemic heart disease. The matters are REMANDED for the following action: 1. Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, schedule the Veteran for a VA psychiatric examination. The claims file must be provided to the examiner in conjunction with the examination. All indicated tests should be conducted and the results reported. The need for further in-person examination is left to the discretion of the examiner. The examiner should respond to the following question: Is it at least as likely as not (50 percent probability or greater) that the Veteran's claimed acquired psychiatric disorder was aggravated (worsened beyond normal progression) by his service-connected disabilities, including prostate cancer, bronchial asthma, diabetes, left lower extremity peripheral neuropathy, post-inflammatory pigmentation, anemia, and prostatectomy surgical scar? If the examiner finds that a current psychiatric disorder was aggravated, the examiner should attempt to quantify the degree of aggravation beyond the baseline level of the psychiatric disorder prior to the aggravation. A RATIONALE FOR ALL OPINIONS SHOULD BE PROVIDED. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinion must support the conclusions reached with an analysis that is adequate to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. Following the receipt of outstanding records, schedule the Veteran for a VA nerves examination to determine whether the Veteran currently suffers from bilateral upper extremity peripheral neuropathy or diabetic peripheral neuropathy and the etiology of any such diagnosed condition. The claims file must be provided to the examiner in conjunction with the examination. All indicated tests should be conducted and the results reported. The need for further examination is left to the discretion of the examiner. After eliciting a full history, conducting a complete review of the claims file, performing an examination of the Veteran, and completing any clinically indicated diagnostic testing, the examiner must provide an opinion as to the following: (A) For any diagnosed bilateral upper extremity peripheral neuropathy disorder, is it at least as likely as not (i.e. 50 percent or greater probability) that such disorder had its clinical onset during active service, or was manifest within a year of service separation, or was related to any incident of service, to include herbicide exposure? (B) For any diagnosed bilateral upper extremity peripheral neuropathy disorder, is it at least as likely as not (i.e. 50 percent or greater probability) that such disorder was caused by or permanently aggravated by any of his service-connected disabilities? The examiner's opinion should reflect consideration of the Veteran's subjective symptoms of numbness, tingling, and/or pain; and the August 2017 VA examination report indicating the Veteran complained of mild numbness in his bilateral upper extremities. The examiner's opinion should reflect that the Veteran's exposure to Agent Orange is presumed by virtue of his service in Vietnam and that the examiner may not rely solely on the fact that a diagnosed disability is not on the presumptive list of diseases associated with herbicide exposure. Rather, the evaluating clinician must opine as to whether or not there is a direct relationship between any diagnosed nerve disorder of the bilateral upper extremities and the Veteran's in-service herbicide exposure and must provide specific reasons in support of the opinion, to include, as relevant, why any statistical or medical studies are found to be persuasive or unpersuasive, whether there are other risk factors that might be the cause of the Veteran's nerve disorder, and whether the condition has manifested itself in an unusual manner. The examiner is again reminded that the Veteran is competent to report the onset and duration of his symptoms as well as his medical history. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. Following the receipt of outstanding records, schedule the Veteran for a VA heart examination to determine whether the Veteran currently suffers from ischemic heart disease. The claims file must be provided to the examiner in conjunction with the examination. All indicated tests should be conducted and the results reported. The need for further examination is left to the discretion of the examiner. After a review of the claims file, including any records obtained pursuant to this remand, and examination of the Veteran, the examiner should provide an opinion as to whether the Veteran currently has ischemic heart disease or has had ischemic heart disease anytime during the appeal period. The examiner's opinion should reflect consideration of a September 2016 private treatment record noting a history of coronary atherosclerosis (VBMS Medical Treatment Record, received November 9, 2017), VA treatment records dated October 2016 and October 2017 noting a past medical history of coronary artery disease (VBMS CAPRI, received May 2, 2018), October 2020 VA opinion indicating the Veteran has a diagnosis of ischemic heart disease, and November 2020 VA opinion indicating the Veteran does not have diagnosis of coronary artery disease and did not have a diagnosis of ischemic heart disease. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mariah N. Sim, 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.