Citation Nr: 21065624 Decision Date: 10/26/21 Archive Date: 10/26/21 DOCKET NO. 17-20 192 DATE: October 26, 2021 REMANDED Entitlement to service connection for essential tremors/Parkinson's disease and/or Parkinsonism, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1974 to May 1977. This case is before the Board of Veterans' Appeals (Board) on appeal from a Department of Veterans Affairs (VA) Regional Office (RO) rating decision that denied entitlement to service connection for essential tremor associated with herbicide exposure, finding the Veteran that essential tremor was not on the list of diseases that are presumed to be due to herbicide exposure. By way of history, the Veteran's initial claim was denied in a March 2007 rating decision, along with the denial of service connection for, inter alia, diabetes mellitus, type II. The Veteran's Notice of Disagreement (NOD) was received in March 2007. However, the NOD was limited to the denial of service connection for diabetes mellitus, type II. In June 2012, the Veteran again claimed service connection for essential tremor. Before the RO issued a rating decision addressing the issue of service-connection for essential tremor, the Board, in an August 2012 decision, granted service connection for diabetes mellitus as a result of exposure to herbicide agents while serving in Thailand during the Vietnam era. Accordingly, exposure to in-service herbicides has been conceded. In April 2013 and September 2014 and May 2015 rating decisions, the RO denied the claim of service connection for essential tremor on the basis that new and material evidence had not been received sufficient to reopen the previously denied claim. Also, in the September 2014 and May 2015 rating decisions, the RO denied service connection for Parkinson's disease based on a finding of no diagnosis. The Veteran's NOD was received in September 2015. The RO issued a Statement of the Case in March 2017, and the Veteran timely appealed to the Board with an April 2017 VA Form 9, substantive appeal. In November 2019 the Board remanded the case to the RO for further development and adjudicative action. In that remand, the Board found that new and material evidence had been received within the one-year appeal period following the March 2007 rating decision, and therefore, the claim remained pending under 38 C.F.R. § 3.156(b). Entitlement to service connection for essential tremors/Parkinson's disease. The record shows a diagnosis of essential tremors and herbicide exposure has been conceded. In the November 2019 remand, the Veteran was to be scheduled for a new VA examination to determine the nature and etiology of any currently diagnosed essential tremors or Parkinson's disease, and for the clinician to address the article titled "Veterans and Agent Orange: Update 2014" (submitted by the Veteran in March 2016). It does not appear that any examination was conducted. At the time of the rating decision on appeal, the Veteran's essential tremor was not one of the listed diseases that is presumed to be due to in-service herbicide exposure. However, effective January 1, 2021, the National Defense Authorization Act for Fiscal Year 2021 added Parkinsonism to 38 U.S.C. § 1116 (a)(2) as a condition presumed to be caused by in-service herbicide agent exposure. The dispositive issue in this case, therefore, is whether the Veteran's essential tremor is a type of Parkinsonism. VA treatment records show longstanding treatment for essential tremors (ET) to include various medications, the Veteran underwent surgery in January 2016 in which a deep brain stimulator (DBS) was placed in his brain. Notably, in a June 2016 internal medicine note, the doctor notes the Veteran's history of essential tremor and DBS "wondering if there could be a parkinsonian spectrum occurring here as well." The doctor seeks consult from a fellow treating physician to address the questions of whether DBS for ET can interfere with the manifestation of parkinsonian symptoms or partially treat Parkinson's disease symptoms at the same time, thus obscuring the diagnosis. Finally, in July 2016 the doctor notes "low suspicion for Parkinson." Notwithstanding the above VA treatment records, the record remains unclear as to whether the Veteran's essential tremor is a type of Parkinsonism. Accordingly, a remand is necessary in order to obtain all outstanding VA treatment records dated from March 2017 to present; and, to obtain a medical opinion as to whether his essential tremor meets the criteria for a diagnosis of Parkinsonism. Accordingly, a remand is necessary in order to obtain another VA examination and medical opinion that adequately addresses facts of this case and the previous remand directives issued by the Board in November 2019. See Stegall v. West, 11 Vet. App. 268, 271 (1998); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The matter is REMANDED for the following actions: 1. Obtain and associate with the claims file all outstanding VA medical records, to include those from March 2017 to the present. Then, schedule the Veteran for an VA neurological examination, if possible, with a neurologist or internal medicine specialist. Upon review of this remand, the entire claims file, the November 2019 remand, and all VA treatment records, the examiner is requested to offer an opinion as to the following: A. Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's longstanding essential tremors (ET) is a type of Parkinsonism? B. Whether it is as likely as not that the Veteran's January 2016 deep brain stimulator (DBS) for his ET, as likely as not, interfered with the manifestation of parkinsonian symptoms, or partially treated Parkinson's disease symptoms at the same time, thus obscuring a Parkinson's diagnosis? If no, it should be explained why this is so. If the Veteran's ET is not considered a type of Parkinsonism, then, is it as likely as not that the ET had its onset during service or is otherwise related to an in-service injury or disease? In offering the aforementioned opinions, the clinician should consider and specifically address the following: (1) the article titled "Veterans and Agent Orange: Update 2014" (submitted by the Veteran in March 2016), (2) the June 2016 VA treatment record in which the doctor noted the Veteran's history of ET and DBS "wondering if there could be a parkinsonian spectrum occurring here as well," and questions whether DBS for ET can interfere with the manifestation of parkinsonian symptoms or partially treat Parkinson's disease symptoms at the same time, thus obscuring a Parkinson's diagnosis, and (3) the July 2016 VA treatment record noting "low suspicion for Parkinson." A complete rationale for any opinion must be provided. L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Ardalan, Associate 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.