Citation Nr: 21065973 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 00-09 565A DATE: October 28, 2021 REMANDED Entitlement to service connection for right wrist and hand as secondary to a service-connected right shoulder disability is remanded. Entitlement to service connection for left wrist and hand as secondary to a service-connected left shoulder disability is remanded. Entitlement to service connection for a musculoskeletal disability other than the elbows, wrists, arms, hands, shoulders, or cervical spine, as due to chemical exposure is remanded. Entitlement to service connection for a genitourinary disability other than erectile dysfunction, to include prostate cancer, as due to chemical exposure or medication prescribed for service-connected disabilities is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from August 1960 to August 1962. These matters come before the Board of Veterans Appeals (Board) on appeal from April 2000, March 2003, and October 2007 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). In a March 2020 Board decision, service connection was denied. The Veteran appealed and in March 2021, the Court of Appeals for Veterans Claims (Court), pursuant to a Joint Motion for Partial Remand (JMPR), vacated and remanded the Board decision. The Court did not disturb the Board's denial of service connection for bilateral wrist and hand arthritis on a direct basis. 1. Entitlement to service connection for right wrist and hand as secondary to a service-connected right shoulder disability is remanded. 2. Entitlement to service connection for left wrist and hand as secondary to a service-connected left shoulder disability is remanded. The Board finds that a new VA opinion is needed before a decision may be rendered on the claim regarding service connection for bilateral wrist and hand arthritis as secondary to the Veteran's service-connected right shoulder disability. As noted in the JMPR, the VA nexus opinion obtained in May 2007 did not provide an opinion regarding aggravation and did not provide a rationale for its conclusions. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-141 (2013); Stefl v. Nicholson, 21 Vet. Appt. 120, 124 (2007). As such, a new opinion should be obtained upon remand which addresses all aspects of a secondary theory of entitlement. 3. Entitlement to service connection for a musculoskeletal disability other than the elbows, wrists, arms, hands, shoulders, or cervical spine, as due to chemical exposure, is remanded. The Board finds that a new opinion is needed before a decision may be rendered on the claim regarding service connection for a musculoskeletal disability other than the elbows, wrists, arms, hands, shoulders, or cervical spine, as due to chemical exposure. An opinion was obtained in August 2018 in response to a March 2017 Board remand requesting that a VA examiner determine if a musculoskeletal condition was present other than for the elbows, wrists, arms, hands, shoulders, or cervical spine, and whether it was related to service. However, the opinion did not discuss a May 2005 diagnosis of lumbar spondylosis and whether it was a musculoskeletal disability other than those listed. As such, the August 2018 opinion did not substantially comply with the March 2017 remand. See Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, remand is needed for a new opinion to ensure compliance with the prior remand requests. 4. Entitlement to service connection for a genitourinary disability other than erectile dysfunction, to include prostate cancer, as due to chemical exposure or medication prescribed for service-connected disabilities, is remanded. The Board also finds that a new VA opinion is needed before a decision may be rendered on the claim regarding service connection for a genitourinary disability. As discussed in the JMPR, in determining that the Veteran's genitourinary disability was less likely than not related to Asterol prescribed for his service-connected skin disability, an August 2018 VA examiner did not address a March 1988 record noting that his prostate was "1+" and did not determine whether this indicated that benign prostatic hyperplasia (BPH) was present in 1987, prior to the discontinuation of Asterol in 1997. The examiner also relied upon the fact that Asterol was discontinued because of neurotoxic symptoms and the Veteran did not have a neurogenic bladder. However, the examiner did not discuss an August 1988 letter that indicated that the Veteran underwent a "cystonefogram which demonstrated a neurogenic bladder" and a June 2000 report that he had been diagnosed with "a toxic neurogenic bladder secondary to exposure of chemicals." As these records are pertinent to the Veteran's claim, any provided medical opinion must reconcile the records to the nexus determination. As such, a new opinion is needed upon remand. The matters are REMANDED for the following action: 1. Obtain addendum VA opinions from the VA clinician who provided the August 2018 opinion regarding the claims on appeal. If that clinician is no longer available, obtain an opinion from another appropriate VA clinician. The clinician is asked to review the entirety of the extensive medical record, specifically to include prior VA examinations and opinions, a March 2013 private opinion, and lay statements submitted by the Veteran. Following review of the claims file, the clinician is asked to address: Bilateral Wrists and Hands: (a.) Whether it is at least as likely as not that the claimed right wrist and hand and left wrist and hand disabilities were proximately caused or aggravated (i.e., worsened beyond natural progression) by the Veteran's service-connected right shoulder disability. (b.) The clinician is reminded that the term "aggravated" as used in 38 C.F.R. § 3.310(b), does not require that there be "permanent worsening" of the nonservice-connected disability. Instead, secondary service connection is warranted for "any incremental increase in disability and any additional impairment of earning capacity in nonservice-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase regardless of its permanence." See Ward v. Wilkie, 31 Vet. App. at 239. (c.) The clinician should specifically discuss the Veteran's medical history regarding the development and progression of his bilateral wrist and hand disabilities in light of his service-connected right shoulder disability. If medical literature is relied upon in rendering this determination, the clinician should identify and specifically cite each reference material used. (d.) All opinions should be accompanied by supporting rationale explaining how the clinician arrived at the conclusions expressed. (e.) If the clinician determines that s/he cannot provide an opinion without resorting to speculation, the clinician should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. Musculoskeletal Disability: (a.) Whether it is at least as likely as not that the claimed musculoskeletal disability other than the elbows, wrists, arms, hands, shoulders, or cervical spine, is the result of the Veteran's active service, specifically to include as due to chemical exposure. The clinician is specifically asked to address the May 2005 diagnosis of lumbar spondylosis and whether it was a musculoskeletal disability other than those listed and whether it is related to service, including chemical exposure. (b.) All opinions should be accompanied by supporting rationale explaining how the clinician arrived at the conclusions expressed. (c.) If the clinician determines that s/he cannot provide an opinion without resorting to speculation, the clinician should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. Genitourinary Disability: (a.) Whether it is at least as likely as not that the claimed genitourinary disability other than erectile dysfunction, to include prostate cancer, is the result of active service, specifically to include as due to chemical exposure; and (b.) Whether it is at least as likely as not that the claimed genitourinary disability was proximately caused or aggravated (i.e., worsened beyond natural progression) by the Veteran's service-connected skin disability, specifically to include treatment by Asterol. (c.) The clinician is reminded that the term "aggravated" as used in 38 C.F.R. § 3.310(b), does not require that there be "permanent worsening" of the nonservice-connected disability. Instead, secondary service connection is warranted for "any incremental increase in disability and any additional impairment of earning capacity in nonservice-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase regardless of its permanence." See Ward v. Wilkie, 31 Vet. App. at 239. (d.) The clinician is specifically asked to address: 1. March 1988 record noting that the Veteran's prostate was "1+" and whether this indicated that BPH was present in 1987, prior to the discontinuation of Asterol in 1997; 2. August 1988 letter that indicated that the Veteran underwent a "cystonefogram which demonstrated a neurogenic bladder;" and 3. June 2000 report that the Veteran had been diagnosed with "a toxic neurogenic bladder secondary to exposure of chemicals." (e.) The clinician should specifically discuss the Veteran's medical history regarding the development and progression of his genitourinary disability in light of Asterol treatment for his service-connected skin disability. If medical literature is relied upon in rendering this determination, the clinician should identify and specifically cite each reference material used. (f.) All opinions should be accompanied by supporting rationale explaining how the clinician arrived at the conclusions expressed. (g.) If the clinician determines that s/he cannot provide an opinion without resorting to speculation, the clinician should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. 2. Ensure the requested opinions are obtained and associated with the claims file. After the above development and any additionally indicated development has been completed, readjudicate the issues on appeal. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Rachel E. Jensen, 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.