Citation Nr: 21065352 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 19-18 749A DATE: October 25, 2021 REMANDED Entitlement to service connection for bilateral lower extremity peripheral neuropathy, to include as due to exposure to herbicide agents, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1962 to July 1967 and from June 1972 to October 1975, which included service in the Republic of Vietnam from August 1965 to September 1966. He had additional service in the United States Army Reserves. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an April 2018 rating decision. In decisions dated in June 2020 and June 2021, the Board remanded the case to the agency of original jurisdiction (AOJ) for additional development and adjudication. The case has since been returned to the Board for appellate review. 1. Entitlement to service connection for bilateral lower extremity peripheral neuropathy, to include as due to exposure to herbicide agents, is remanded. In response to the Board's June 2021 remand, the AOJ obtained a negative VA nexus opinion in August 2021 in connection with the Veteran's service connection claim for bilateral lower extremity peripheral neuropathy. The examiner, a medical doctor with a noted specialty in family medicine, concluded that there was no evidence of peripheral neuropathy within one year of service in light of the information provided in an article on the Department of Veterans Affairs (VA) Office of Patient Care Services/Public Health's website regarding VA's presumed association between early onset peripheral neuropathy and exposure to herbicide agents. See Peripheral Neuropathy and Agent Orange, Public Health, United States Department of Veterans Affairs, https://www.publichealth.va.gov/exposures/agentorange/conditions/peripheral_neuropathy.asp. The examiner added that peripheral neuropathy stemming from Agent Orange exposure should be in the fingertips as well as the feet as it should be in the periphery; and if it was not originally in both sites, data suggested that it would worsen to encompass both. However, the examiner's report that initial symptoms should be in both the fingertips and feet appears to be inconsistent with the information that the examiner included from the article in the opinion. The website states that symptoms of peripheral neuropathy could be present "in the toes or fingers in early stages. This may spread to the feet or hands and may cause burning, throbbing or shooting pain that is worse at night. Other symptoms include pain equally in both sides of the body (in both hands or in both feet) ..." (emphasis added). The examiner stated that there were too many inconsistencies in linking the peripheral neuropathy to Agent Orange whereas there was a more plausible explanation that the nerve issue stemmed from a back issue. The examiner further indicated that if the opinion was "overturned," it needed to be done in conjunction with an electromyography (EMG) and a neurologist's opinion. The Board consequently finds that it is unclear whether there is a sufficient foundation for the August 2021 VA examiner's opinion as the examiner suggested that a greater level of specialization as well as additional EMG testing would be necessary to provide an adequate opinion. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010) (noting that it must be clear that the examiner has indeed considered all procurable and assembled data by obtaining all tests and records that might reasonably illuminate the medical analysis). The record also shows that although the Veteran was previously afforded a VA examination related to peripheral neuropathy in April 2021, the examination was completed by an APRN nurse practitioner and no EMG studies were performed. Based on the foregoing, the Board finds that the August 2021 medical opinion is inadequate; and a remand is warranted to obtain an additional VA examination and medical opinion from a neurologist that includes EMG testing if deemed necessary by the examiner. To the extent that peripheral neuropathy may be considered a chronic disease under 38 C.F.R. § 3.309(a), the examiner should also address with the disorder manifested within a year of either of the Veteran's periods of active duty service. The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any health care providers who have provided treatment for his bilateral lower extremity peripheral neuropathy. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA medical records, to include records dated since June 2021. 2. After the preceding development in paragraph 1 is completed, schedule the Veteran for a VA examination with a neurologist that addresses the nature and etiology of any bilateral lower extremity peripheral neuropathy that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner, to include EMG testing, should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. A clear explanation for all opinions based on specific facts of the case as well as relevant medical principles is needed. The Veteran is competent to attest to observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should clearly identify all current peripheral neuropathy of the right and/or left lower extremity. For each identified disorder, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that such disorder manifested during a period of active duty service; manifested within one year of the Veteran's discharge from either period active duty service; or is otherwise related to active duty service, to include the Veteran's exposure to herbicide agents therein (notwithstanding the fact that it may not be a presumed association). If the examiner concludes that further testing or research is necessary to provide an opinion, to include EMG testing, such testing or research should be conducted. In providing an opinion, the examiner should address the August 2021 VA medical opinion in which the examiner indicated that EMG testing might be necessary to provide a medical opinion in relation to the Veteran's claim. 3. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and his representative a supplemental statement of the case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.C. Spragins, 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.