Citation Nr: 21064137 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 16-14 253 DATE: October 19, 2021 REMANDED Entitlement to service connection for peripheral neuropathy of the left upper extremity (LUE) is remanded. Entitlement to service connection for peripheral neuropathy of the right upper extremity (RUE) is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1967 to September 1968. These matters come before the Board of Veterans' Appeals (Board) on appeal from a rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2020, the denied service connection for peripheral neuropathy of the bilateral upper extremities (BUE). The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). An Order of the Court, dated in June 2021, granted a Joint Motion for Remand (JMR), vacating the July 2020 Board decision with regard to the issues listed above and remanding the claims to the Board for action consistent with the terms of the JMR. To ensure that the VA has met its duty to assist, an additional remand is necessary. Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for LUE peripheral neuropathy is remanded. 2. Entitlement to service connection for RUE peripheral neuropathy is remanded. Issue 1 and 2: The Veteran contends that he has BUE peripheral neuropathy due to service. Alternatively, he contends that he has BUE peripheral neuropathy due to service-connected diabetes mellitus and/or service-connected bilateral lower extremity (BLE) peripheral neuropathy. He reports that his condition is characterized by numbness, tingling, loss of sensation and pain. See C&P Exam (April 2015; January 2020). A May 2019 Board decision found the April 2015 VA examination was internally inconsistent, and subsequent VA treatment notes necessitated further examination to clarify whether the Veteran had a current disability of the upper extremities. The Board remanded the claim for a new VA examination to "determine the nature and etiology of the Veteran's upper extremities pain, loss of sensation and weakness" and "identify by diagnosis(es) the Veteran's upper extremity condition(s) that would account for pain and numbness." Here, although VA obtained a July 2019 VA examination, it is inadequate for adjudicative purposes. Specifically, although intermittent pain and paresthesias and/or dysesthesias of the right upper extremity were noted, the examiner did not provide a diagnosis for the right upper extremity condition. See C&P Exam (January 2020). Additionally, the examiner noted that the questionnaire was not the appropriate DBQ for diabetic peripheral neuropathy, and there is "no OBJECTIVE evidence of a RIGHT sided peripheral neuropathy on exam." However, no explanation was provided as to why the proper DBQ was not completed or whether any further diagnostic tests could have been performed to provide any necessary objective findings to properly diagnose the Veteran's condition. It is also noted that a medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record. See Stefl v. Nicholson, 21Vet. App.102, 124-25. A "medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two." Nieves-Rodriguez v. Peake, 22Vet. App.295, 301 (2008). To ensure that VA has met its duty to assist, remand is required. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that it is adequate). Moreover, a remand by the Board imposes upon the Secretary of VA a concomitant duty to ensure compliance with the terms of the remand. Where remand orders of the Board are not complied with, the Board errs in failing to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). In remanding this matter, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion to determine the nature and etiology of any bilateral upper extremity nerve disorder to include any peripheral neuropathy of either the RUE and/or LUE. The entire claims file, including a complete copy of this REMAND, must be made available to the clinician for review. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression, and severity of any symptom consistent with peripheral neuropathy of the upper extremities. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge, or literature, etc., relied upon in reaching the conclusion(s). The clinician must opine on: Direct Service Connection (a) Whether the Veteran has a RUE and/or LUE nerve disorder that at least as likely as not (a 50 percent or greater probability) (1) began during active service, (2) manifested within one year after discharge from service, (3) was noted during service with continuity of the same symptomatology since service, or (4) is related to an in-service injury, event, or disease, including in-service exposure to an herbicide agent. Secondary Service Connection (b) Whether the Veteran has a RUE and/or LUE nerve disorder that at least as likely as not (a 50 percent or greater probability) is (1) caused by or the result of, or (2) aggravated by service-connected diabetes mellitus and/or service-connected bilateral lower extremity peripheral neuropathy. Consider the Veteran's theory that his BUE nerve symptoms are due to his military service, to include herbicide agent exposure. Discuss the Veteran's service treatment records, post-service complaints and medical records, and lay assertions, including those proffered during VA treatment and on examination. In doing so, address whether his reports about his symptoms align with how the currently diagnosed disabilities are known to develop or are his reports generally inconsistent with medical knowledge or implausible. Noting review of the claims file does substitute for direct commentary on the above referenced evidence. Note (1): A negative medical opinion may not be predicated solely on the absence of documented in-service complaints or findings. NOTE (2): If the clinician rejects any history (e.g., injury, symptoms in or since service, treatment, etc.), he/she must indicate this in the examination report and provide a rationale for so doing. 2. Ensure that the VA medical opinion obtained include a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinion 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. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Edwards 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.