Citation Nr: 21065131 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 18-18 887 DATE: October 25, 2021 REMANDED Entitlement to service connection for a right upper extremity neurological disability, to include right upper arm radiculopathy, is remanded. Entitlement to service connection for a right hip disability, to include right hip total replacement residuals, is remanded. REASONS FOR REMAND The Veteran had active service from February 1971 to February 1992. In February 2020, the Board of Veterans' Appeals (Board) denied service connection for right upper arm radiculopathy and remanded the issue of service connection for right hip total replacement residuals to the Agency of Original Jurisdiction for further development. The Veteran subsequently appealed to the United States Court of Appeals for Veterans Claims (Court). In January 2021, the Court granted the Parties' Joint Motion for Partial Remand; vacated that portion of the February 2020 Board decision which denied service connection for right upper arm radiculopathy; and remanded that issue to the Board for action in accordance with the Joint Motion for Partial Remand. In August 2021, the Board notified the Veteran that the American Legion had informed the Board that it did not represent him. The Veteran was informed of his right to appoint a representative in the instant appeal. The Board clarified that if he did not respond within 30 days of the date of the Board's letter, the Board would assume that he wished to represent himself. A response from the Veteran was not subsequently received. 1. Entitlement to service connection for a right upper extremity neurological disability, to include right upper arm radiculopathy, is remanded. The Joint Motion for Partial Remand indicates that the report of the February 2016 VA peripheral nerve examination was inadequate. The report of the February 2016 Department of Veterans Affairs (VA) peripheral nerve examination states that the Veteran complained of recurrent right hand pain and numbness. The examiner reported that the Veteran had "symptoms attributable to any peripheral nerve conditions" including constant moderate right upper extremity pain and moderate right upper extremity numbness. The VA physician concluded that "there is no clinical evidence of right upper extremity radiculopathy at this moment" and "medical opinion does not apply." Given the concurrent conflicting findings as to whether the Veteran had right upper extremity peripheral nerve symptoms, the Board concludes that the February 2016 VA examination report is of essentially no probative value. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In light of the cited deficiency in the February 2016 examination report and the directions set forth in the Parties' Joint Motion for Partial Remand, the Board finds that further VA evaluation is needed. 2. Entitlement to service connection for a right hip disability, to include right hip total replacement residuals, is remanded. A March 2020 VA hip evaluation states that the "right hip condition is less likely as not aggravated bt the service connected lumbar condition" as there was "no evidence of aggravation of the right hip condition was found at this exam by the service connected lumbar condition residuals." The examiner provided no specific rationale for his conclusion that there was "no evidence of aggravation of the right hip condition." The examination report is therefore of essentially no probative value. The Board finds that further VA hip evaluation is needed. Clinical documentation dated after April 2020 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who treated him for any right upper extremity neurological and right hip disabilities. Make two requests for authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain any VA treatment records not already of record, to include those pertaining to treatment after April 2020. 3. Schedule the Veteran for a VA neurological examination conducted by a medical doctor to ascertain the nature and etiology of any right upper extremity neurological disability. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all right upper extremity neurological disabilities found. If radiculopathy and other neurological disability are not identified, the examiner should specifically state that fact. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified right upper extremity neurological disability had its onset during active service or is related to any incident of service. (c) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified right upper extremity neurological disability is due to or the result of the right clavicular fracture residuals and the other service-connected disabilities. (d) Opine whether it at least as likely as not (50 percent probability or greater) that any identified right upper extremity neurological disability has been aggravated (increased in severity beyond the natural progression of the disorder) by the right clavicular fracture residuals and the other service-connected disabilities. 4. Schedule the Veteran for a VA hip examination conducted by a medical doctor to ascertain the nature and etiology of the right hip replacement residuals. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all right hip disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified right hip neurological disability had its onset during active service or is related to any incident of service. (c) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified right hip disability is due to or the result of the lumbar spine spondylolysis, spondylolisthesis, degenerative disc disease, degenerative joint disease, canal stenosis, and strain and the other service-connected disabilities. (d) Opine whether it at least as likely as not (50 percent probability or greater) that any identified right hip disability has been aggravated (increased in severity beyond the natural progression of the disorder) by the lumbar spine spondylolysis, spondylolisthesis, degenerative disc disease, degenerative joint disease, canal stenosis, and strain and the other service-connected disabilities. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Casula 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.