Citation Nr: 21063460 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 15-09 166 DATE: October 14, 2021 REMANDED Entitlement to service connection for right upper extremity neuropathy is remanded. Entitlement to service connection for left upper extremity neuropathy is remanded. Entitlement to service connection for right lower extremity neuropathy is remanded. Entitlement to service connection for left lower extremity neuropathy is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1967 to April 1971. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2014 rating decision issued by a Regional Office (RO) of the United States Department of Veterans Affairs (VA). In an October 2019 decision, the Board remanded the claims, in relevant part, to obtain an addendum medical opinion regarding the etiology of the Veteran's claimed peripheral neuropathy disabilities. A VA addendum medical opinion was obtained in December 2019, which adequately addressed the requisite inquiries. The VA examiner explained that the cause of the Veteran's peripheral neuropathy disabilities is unknown, and all neurological investigations and sources have been exhausted on the issue. The VA examiner clearly indicated that he considered all procurable and assembled data and remained unable to determine the cause of the Veteran's peripheral neuropathy disabilities. This VA medical opinion is adequate and complies with the factors set forth in Jones v. Shinseki, 23 Vet. App. 382 (2010) regarding inconclusive medical opinions. See id. at 390-91. In June 2020, the Veteran submitted VA Form 21-4138, Statement in Support of Claim, where he indicated his belief that the Board's October 2019 remand decision ordered an in-person examination versus a medical opinion based on a review of the record. He stated this was "unfair," but did not articulate why an in-person examination was required to resolve the appeal. First, the October 2019 Board remand only requested an addendum VA medical opinion and did not instruct the RO to obtain an in-person examination. Second, an in-person examination is only required when "necessary to decide the claim[s]." See 38 C.F.R. § 3.159(c)(4)(i). The current disability element of a service connection claim is not in dispute, and thus, only a medical opinion is necessary to resolve the issue of whether the Veteran's peripheral neuropathy disabilities are the result of the Veteran's active duty service. Lastly, the December 2019 VA examiner categorically stated that "an additional examination will not aid in any future information to help resolve [the] claimed contentions." The Board finds no need for an in-person examination, one was not requested by the October 2019 Board remand, the VA examiner has stated that an examination is not necessary, and the Veteran has not articulated, yet alone proven, that he would be prejudiced in the absence of an in-person examination. In light of the above analysis, the Board finds that the RO substantially complied with the Board's October 2019 remand directive regarding the procurement of an adequate VA medical opinion. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In the October 2019 decision, the Board also remanded the claims to afford the Veteran the opportunity to identify any further outstanding medical evidence. In October 2019, the RO sent notice to the Veteran soliciting identification of outstanding medical records. The Veteran responded in October 2019 that his disabilities were only treated by VA providers, and denied that his conditions have ever been treated by private health care providers. See October 2019 VA Form 21-4138, Statement in Support of Claim. In October 2019 and April 2020, the RO uploaded a significant amount of additional VA treatment records to the Veteran's electronic claims file. See Compensation and Pension Record Interchange (CAPRI) documents received October 8, 2019 and April 24, 2020. The Board's independent review shows that the October 2019 CAPRI upload contains an October 31, 2018 document indicating that the Veteran was seen by an outside neurologist, and the private neurological records were scanned into VA's computerized patient records system (CPRS) using the VISTA imaging process. Regrettably, these private neurological records located in the VISTA imaging display of the Veteran's CPRS file were not associated with the electronic claims file for evidentiary review. These records may contain evidence relevant to the Veteran's appeal, and the Board may not proceed with final adjudication of the Veteran's claims without procuring this outstanding relevant evidence, as to do so may result in prejudice to the Veteran. As the outstanding records are in VA's actual possession, and the RO did not substantially comply with the Board's October 2019 remand instructions directing the RO to obtain all available treatment records concerning the Veteran's claims, a remand is required to obtain the missing October 2018 private neurological records located in the Veteran's CPRS file. See Stegall, 11 Vet. App. at 271. As the Board is remanding the claims as identified above, upon remand, the RO is also requested to associate any updated VA treatment records from April 2020 to the present with the Veteran's electronic claims file. See Bell v. Derwinski, 2 Vet. App. 611 (1992); 38 C.F.R. § 3.159(c)(2) and (3). The matters are REMANDED for the following action: 1. Undertake appropriate efforts to associate the October 31, 2018 non-VA care neurological records, as referenced in the October 2019 CAPRI upload, with the electronic claims file. A notation in the CAPRI record indicates that these records can be accessed using the Tools menu of CPRS under the category VISTA imaging display, and the subcategory TIU Title. 2. Obtain the Veteran's VA treatment records for the period from April 2020 to the present. Cynthia M. Bruce Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Galante, 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.