Citation Nr: 21064506 Decision Date: 10/20/21 Archive Date: 10/20/21 DOCKET NO. 04-30 834 DATE: October 20, 2021 REMANDED The claim of entitlement to service connection for bilateral leg tremors, to include as secondary to service-connected residuals of in-service back injury, is remanded. The claim of entitlement to service connection for balance problems, to include as secondary to service-connected residuals of in-service back injury, is remanded. The claim of eligibility for financial assistance for an automobile and adaptive equipment or adaptive equipment only is remanded. The claim of eligibility for financial assistance for specially adapted housing or special home adaptation is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from October 1972 to February 1975. This appeal to the Board of Veterans' Appeals (Board) arose from January 2004 and June 2005 rating decisions. In August 2006, the Veteran and a witness testified during a Board hearing in Washington, D.C., a transcript of which is of record. In July 2007, June 2011, September 2013, and March 2017, and March 2020, the issues on appeal were remanded for further development. The appeal has now been returned to the Board. Unfortunately, remand is again required. By way of history, in March 2017, the Board remanded the claims involving leg tremors and balance problems so that an addendum medical opinion could be obtained to address the etiology of the Veteran's claimed leg tremor disorder and balance problems. The remand noted that a January 2012 VA examination had found that the Veteran had non-physiological tremors of the legs which were likely related to somatization disorder or conversion disorder and were not due to her service-connected back disability. The examiner explained, in pertinent part, that somatization disorder was a syndrome of nonspecific physical symptoms that cannot be fully explained by a known medical condition and which could be caused or exacerbated by anxiety, depression, or interpersonal conflicts. The Board noted that an adequate medical opinion was still needed to address whether the Veteran's somatization/conversion disorder and tremors/balance problems could be caused or aggravated by her service-connected psychiatric disorder and whether they had been aggravated by her service-connected back disability Addendum medical opinions were obtained in December 2017 and January 2018. The addendum medical opinion obtained in December 2017 was from VA physician assistant B.H. who had conducted the prior January 2012 examination. She discussed at length the Veteran's medical history and why the claimed symptoms were not likely due to a neurological or other medical disorder, and stated that they were a symptom of somatization disorder. She wrote that the leg tremors were not aggravated by residuals of a back injury. In a follow-up e-mail, she wrote that regarding whether the condition had been due to or aggravated by depressive disorder, this question would need to be answered by a mental health examiner. In January 2018, a VA addendum opinion was then obtained from VA psychologist C.M. who reviewed the claims file but did not perform an in-person evaluation of the Veteran. He found that the Veteran's condition was less likely than not due to or the result of a service-connected condition, and as rationale he wrote that there was no organic disease, and therefore "depression would not be a cause or an aggravating factor in a condition that does not exist." He noted that the condition had been previously found to be related to somatization disorder or conversation disorder, but also wrote that "Depression does not simply progress and cause nervous system symptoms like the veteran is complaining of..." The Board previously found the January 2018 medical opinion to be inadequate, as it appeared to completely dismiss the Veteran's symptoms as imaginary and therefore not something that can be connected to any underlying etiology. It also appears that the examiner was not provided with the questions in a clear way, as he was asked to address aggravation of anorganic nervous system disorder, but the Board's prior remand asked for opinions on "any disability(ies) manifested by leg tremors and balance problems," which would include any psychiatrically-based disorders. The Board noted that the January 2018 opinion focused only on the fact that depression would not cause organic nervous disorder symptoms, but a medical opinion is still required to consider the Veteran's underlying psychiatric origin for a separate disorder of somatization or conversion disorder. The April 2020 Board remand discussed somatization disorder at length, and noted VA examination(s) should be afforded to the Veteran to evaluate her current symptoms and to determine whether she has symptoms with a psychiatric etiology, such as somatic symptom disorder, and also whether the Veteran had a functional neurological disorder that was caused or aggravated by her service-connected depressive disorder. Post-remand, the March 2021 VA examination by E.W., FNP confirmed a diagnosis of essential tremors. The March 2021 VA psychiatric examination by M.G., PsyD neither confirmed nor explicitly denied existence of a somatic symptom disorder. A nexus opinion by M.G., PsyD stated that the somatic symptoms were unrelated to the Veteran's major depressive disorder, and that a medical opinion was unable to be provided due to the Veteran's limited cognitive abilities. Nexus opinions were also proffered by the same clinician stating that leg tremors/balance problems were unrelated to the Veteran's major depressive disorder, and that a medical opinion was unable to be provided due to the Veteran's limited cognitive abilities. Remand for an addendum opinion is required as the examination findings are incomplete. If the Veteran's cognitive abilities preclude an opinion, the examiner should explain why, and note having obtained all procurable medical evidence before declining to offer an opinion. Moreover, it is unclear whether the Veteran has somatic symptoms, and if so, whether such warrant a diagnosis of a "somatic symptom disorder." On remand, the VA examiner should clearly state the findings on this point. As noted previously, a decision on the claims of entitlement to service connection for bilateral leg tremors and balance problems are relevant to the outcome of the Veteran's claim for eligibility for specially adapted housing/special home adaptation and automobile with adaptive equipment. As such, the claims are inextricably intertwined, and remand remains required for these issues as well. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician(s). The examiner should clarify whether there is any somatic disorder confirmed on examination. The examiner should opine whether any condition(s) confirmed on examination productive of balance problems, leg tremors, or somatic symptoms are at least as likely as not proximately due to or aggravated beyond the natural progression by service-connected disability. If the Veteran's cognitive abilities preclude the requested opinion, the examiner should explain why, and note having obtained all procurable medical evidence before declining to offer an opinion. (CONTINUED ON NEXT PAGE) 2. Thereafter, readjudicate the claims on appeal. If any benefit remains denied, issue a Supplemental Statement of the Case (SSOC). Evan M. Deichert Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. C. KING 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.