Citation Nr: 21066091 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 10-34 199 DATE: October 28, 2021 ORDER Entitlement to service connection for right lower extremity (RLE) radiculopathy, to include as secondary to service-connected DDD of the lumbar spine, is granted. Entitlement to service connection for left lower extremity (LLE) radiculopathy, to include as secondary to service-connected DDD of the lumbar spine, is granted. REMANDED Entitlement to service connection for a lung disability, to include as due to in-service asbestos exposure, is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected posttraumatic stress disorder (PTSD) and/or service-connected orthopedic disabilities, is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected PTSD and/or prostate cancer, is remanded. Entitlement to service connection for a cervical spine disability, to include as secondary to service-connected degenerative disc disease (DDD) of the lumbar spine, is remanded. Entitlement to service connection for right upper extremity (RUE) peripheral neuropathy, to include as due to in-service exposure to herbicide agents, and to include as secondary to a cervical spine disability, is remanded. Entitlement to service connection for left upper extremity (LUE) peripheral neuropathy, to include as due to in-service exposure to herbicide agents, and to include as secondary to a cervical spine disability, is remanded. Entitlement to service connection for RLE sensory polyneuropathy, to include as due to in-service exposure to herbicide agents, and to include as secondary to service-connected shrapnel wounds and/or DDD of the lumbar spine, is remanded. Entitlement to service connection for LLE sensory polyneuropathy, to include as due to in-service exposure to herbicide agents, and to include as secondary to service-connected shrapnel wounds and/or DDD of the lumbar spine, is remanded. Entitlement to an extension of temporary total evaluation because of surgical treatment requiring convalescence following spinal fusion is remanded. Entitlement to an extension of special monthly compensation (SMC) at the housebound rate under 38 U.S.C. § 1114(s) is remanded. FINDINGS OF FACT 1. Resolving all reasonable doubt in favor of the Veteran, his currently diagnosed RLE extremity radiculopathy is caused by his service-connected DDD of the lumbar spine. 2. Resolving all reasonable doubt in favor of the Veteran, his currently diagnosed LLE extremity radiculopathy is caused by his service-connected DDD of the lumbar spine. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for RLE radiculopathy, to include as secondary to service-connected DDD of the lumbar spine, have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 2. The criteria for entitlement to service connection for LLE radiculopathy, to include as secondary to service-connected DDD of the lumbar spine, have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from August 1969 to April 1972. The Veteran received a Combat Infantry Badge and Purple Heart. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions in November 2013 and May 2018 by the Department of Veterans Affairs (VA) Regional Office (RO). In the November 2013 rating decision, the RO, in pertinent part, denied service connection for GERD, erectile dysfunction, a neck condition, RLE peripheral neuropathy, LLE peripheral neuropathy, neuropathy of the right arm and fingers, and neuropathy of the left arm and fingers. The Veteran appealed that decision. In the May 2018 rating decision, the RO, in pertinent part, denied service connection for asbestosis exposure (lung cancer); granted a temporary total evaluation based on surgical treatment necessitating convalescence following spinal fusion, effective April 20, 2018; and granted SMC based on the housebound criteria being met from April 20, 2018 to August 1, 2018. The Veteran appealed for service connection, for an extension of temporary total evaluation, and for an extension of SMC based on the housebound criteria being met. During the pendency of the appeal, the RO issued rating decisions in May 2018 and October 2018 granting SMC based on the housebound criteria being met from October 3, 2014 to December 1, 2015 and granting SMC based on the housebound criteria being met from August 9, 2018, respectively. The Veteran continued to appeal for an extension of SMC based on the housebound criteria being met. AB v. Brown, 6 Vet. App. 35 (1993) (holding that a claimant is presumed to be seeking the maximum rating). The Veteran testified before a Veterans Law Judge (VLJ) at an August 2011 Travel Board hearing. A transcript of this hearing is of record. In April 2016, the Veteran was notified that the VLJ who held his August 2011 hearing was no longer employed by the Board. The Veteran declined the opportunity for another hearing. 38 C.F.R. § 20.604. This case has an extensive procedural history. In an April 2017 Board decision, the Board, in pertinent part, denied the claims for service connection for GERD, erectile dysfunction, and bilateral lower extremity peripheral neuropathy; and remanded the claims for service connection for a cervical spine disability and bilateral upper extremity peripheral neuropathy for additional development. The Veteran appealed the April 2017 decision to the U.S. Court of Appeals for Veterans Claims (Court). In a September 2018 memorandum decision, the Court vacated that part of the April 2017 Board decision denying service connection for GERD, erectile dysfunction, and bilateral lower extremity peripheral neuropathy and remanded the matters for further development and readjudication. The case was returned to the Board. In a May 2018 Board decision, the Board, in pertinent part, denied the claim for service connection for a cervical spine disability and remanded the claim for bilateral upper extremity peripheral neuropathy. The Veteran appealed the May 2018 Board decision to the Court. In a March 2019 Order of the Court granting a March 2019 Joint Motion for Partial Remand (JMPR), the parties agreed to vacate that part of the May 2018 Board decision denying service connection for a cervical spine disability and remand the matter for further development and readjudication. The case was returned to the Board. In September 2019 and January 2020, the Board remanded the issues on appeal for additional development. The case was returned to the Board, but the requested development was not completed. Most recently, in January 2021, the Board remanded the issues on appeal for additional development. As discussed below, there has not been substantial compliance with the January 2021 remand instructions, so the matters must be remanded. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Following the August 2021 supplemental statement of the case (SSOC), the Veteran submitted additional evidence in support of his appeal. The Veteran filed his substantive appeal in December 2014 and May 2020. Accordingly, under the Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, this evidence is subject to initial review by the Board, because the Veteran did not request in writing that the Agency of Original Jurisdiction (AOJ) initially review such evidence. See 38 U.S.C. § 7105(e)(1) (2018). Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Given the Board's favorable decision in granting service connection for RLE radiculopathy and LLE radiculopathy, the Board finds that all notification and development actions needed to fairly adjudicate the appeal have been accomplished. Service Connection 1. Entitlement to service connection for RLE radiculopathy, to include as secondary to service-connected DDD of the lumbar spine 2. Entitlement to service connection for LLE radiculopathy, to include as secondary to service-connected DDD of the lumbar spine The Veteran asserts that his bilateral lower extremity peripheral neuropathy was caused or aggravated by his service-connected DDD of the lumbar spine. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). As a preliminary matter, the Board notes that the Veteran has a current diagnosis for bilateral lower extremity sensory polyneuropathy, which will be addressed in the remand section. The discussion below will be limited to the findings related to the Veteran's bilateral lower extremity radiculopathy. However, the Board recognizes that the record includes conflicting medical evidence regarding whether the Veteran has a current diagnosis for bilateral lower extremity lumbar radiculopathy. With regard to the medical opinions obtained, as with all types of evidence, it is the Board's responsibility to weigh the conflicting medical evidence to reach a conclusion as to the ultimate grant of service connection. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Board may favor the opinion of one competent medical expert over another if its statement of reasons and bases is adequate to support that decision. Owens v. Brown, 7 Vet. App. 429, 433 (1995). Stated another way, the Board decides, in the first instance, which of the competing medical opinions or examination reports is more probative of the medical question at issue. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300 (2008). VA treatment records from 2009 to 2018 document the Veteran's complaints of burning, tingling, and radiating and shooting pain in his bilateral lower extremities. At multiple VA clinic visits, the Veteran was diagnosed with lumbar radiculopathy of the bilateral lower extremities secondary to his DDD. See August 2009, November 2009, May 2010, November 2010, January 2012, February 2012, May 2012, November 2016, June 2017, and October 2017 VA treatment records. However, in a September 2013 VA Electrodiagnostic Report, there was a finding of no electrodiagnostic evidence of lumbar radiculopathy in both lower extremities. Moreover, at VA spine examinations in May 2012 and March 2019, the VA examiner found no radicular pain or any other signs or symptoms due to radiculopathy. Finally, in July 2020 and June 2021 VA opinions, the VA examiners found that the Veteran's September 2013 electrodiagnostic results were not consistent with radiculopathy. In the same June 2021 VA opinion, the VA examiner explained that the Veteran had undergone decompressive laminectomy of the spine in 2018 for symptoms of lumbar radiculopathy. Private treatment records also document that the Veteran sought treatment for his bilateral lower extremity symptoms. At a June 2016 private visit, the Veteran complained of lumbar pain with radiating pain into his buttocks, groin and down the bilateral legs. Following a review of the Veteran's lumbar MRI, the private treating physician diagnosed the Veteran with chronic midline low back pain with bilateral sciatica. January 2018 private treatment records document the Veteran's complaints of constant, sharp, heavy, achy, stabbing, and burning in his lower back, which radiated into his buttocks, hips, and groin. The Veteran was diagnosed with lumbar disc herniation with radiculopathy. In April 2018, the Veteran underwent a spinal fusion. The April 2018 private operative note indicated that the Veteran was brought to the facility for treatment of lumbar radiculopathy. Based on the totality of the evidence, the Board finds that the evidence is at least in equipoise that the Veteran has a current diagnosis for bilateral lower extremity radiculopathy. Because the Veteran is service-connected for DDD of the lumbar spine, the Board finds that service connection for RLE radiculopathy and LLE radiculopathy as secondary to DDD of the lumbar spine is warranted. Accordingly, resolving all reasonable doubt in favor the Veteran, his service connection claims for RLE radiculopathy and LLE radiculopathy must be granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for a lung disability, to include as due to in-service asbestos exposure, is remanded. The Veteran asserts that his lung disability developed from his in-service exposure to asbestos exposure while working in the motor pool in Germany repairing roads and military vehicles and from clutches, brakes, and engine compartment insulation. He also described being exposed to asbestos from planes, the barracks, and other military buildings. At an April 2018 VA examination, the VA examiner found that there was insufficient evidence to warrant a diagnosis for lung cancer. Noting that the Veteran reported being diagnosed with asbestosis in the 1990's based on testing performed at Michigan State University while working at General Motors, the VA examiner found that there was no objective testing to validate his diagnosis and that his chest x-rays have been normal without signs of asbestos. However, an April 2018 pulmonary function test (PFT) revealed moderate to severe obstruction, which reversed back to normal after a significant bronchodilator response suggestive of asthma. No explanation was provided by the April 2018 VA examination for this PFT finding. Accordingly, the Board finds that the April 2018 VA examination is inadequate for adjudicative purposes. In an August 2021 SSOC, the AOJ referenced the Veteran's VA treatment for respiratory issues in April 2021 and May 2021. Specifically, the AOJ described how the Veteran had a chest x-ray in April 2021 and received VA treatment by pulmonology in May 2021 for breathing trouble assessed with having exertional dyspnea with intermittent wheezing noted over the last three to four months. A review of the record shows that VA treatment records since February 2021 have not been associated with the Veteran's claims file. Because clearly relevant VA treatment records have not been associated with the record, and these records may indicate that the Veteran has a current respiratory disorder, a remand is required to associate with the record VA treatment records since February 2021. See Bell v. Derwinski, 2, Vet. App. 611 (1992); 38 C.F.R. § 3.159(c)(1). Moreover, the Board finds that a remand is also required to obtain a new VA examination and etiological opinion. Given this new information regarding the Veteran's respiratory condition as well as the lack of explanation for the Veteran's April 2018 abnormal PFT findings and suggestion of asthma without any definitive diagnosis, the AOJ should afford the Veteran a new VA examination to confirm any current respiratory diagnosis. Importantly, the VA examiner should not confine the evaluation only to Veteran's claimed asbestosis. Finally, the Veteran should be afforded another opportunity to provide the private treatment records from Michigan State University in the 1990's, including any respiratory testing results. 2. Entitlement to service connection for GERD, to include as secondary to service-connected PTSD and/or service-connected orthopedic disabilities, is remanded. The Veteran asserts that his GERD was caused or aggravated by his service-connected PTSD. In support of his appeal, the Veteran has submitted several medical articles, which discuss how there is a relationship between mental health disorders and gastrointestinal disorders, to include GERD. In a June 2021 VA opinion, the VA examiner opined that the Veteran's GERD was less likely than not incurred in or caused by active duty service. In providing a rationale, the June 2021 VA examiner relied, in part, on the lack of documentation for evidence of treatment or reported symptoms of GERD both during and following service as well as the finding that his GERD was diagnosed 37 years after service in 2009. However, as noted by the Veteran's attorney, in an October 2021 statement, this finding does not consider how GERD can be treated with over-the-counter medication. Additionally, the June 2021 VA examiner opined that the Veteran's GERD was less likely than not caused by his service-connected PTSD. In providing a rationale, the June 2021 VA examiner relied on the findings that medical literature did not show that GERD was attributed to PTSD and that the Veteran had risk factors for gastritis and GERD, including obesity, daily soda consumption, and daily alcohol use, which the Veteran reported drinking on a daily basis from 1970 to 2011. The Board finds that the June 2021 VA examiner did not address the medical literature provided by the Veteran, which suggested a link between GERD and PTSD. Moreover, the June 2021 VA examiner opined that the Veteran's GERD was less likely than not aggravated by his service-connected PTSD. In providing a rationale, the June 2021 VA examiner relied on the finding that there was no objective data that the Veteran met the diagnostic criteria for GERD. This finding does not consider that the Veteran has been diagnosed with GERD during the appeal period. Furthermore, the June 2021 VA examiner found that there were no documented complications of the condition such as Barrett's esophagus, chronic regurgitation, weight loss, or anemia. However, the Board finds that the June 2021 VA examiner did not explain why it was necessary for these conditions to exist in order to show evidence of aggravation by the Veteran's service-connected PTSD. Finally, in an October 2021 statement, the Veteran's attorney discussed the June 2021 VA examiner's determination that the Veteran's GERD was attributed to his obesity and alcohol consumption. The Veteran's attorney explained that the VA examiner did not consider that the Veteran used alcohol to relieve his PTSD symptoms. The VA examiner also did not consider that obesity can serve as an intermediate step between the Veteran's GERD and a service-connected disability. In particular, the Veteran's attorney asserts that the Veteran has several service-connected disabilities which prevent him from maintaining a proper weight, such as his PTSD, right knee arthritis, degenerative disc disease (DDD) of the lumbar spine, left knee stain, and left ankle osteoarthritis. Additionally, the Veteran's attorney noted how the June 2021 VA examiner also did not substantially comply with the January 2021 remand instructions when the VA examiner failed to address the onset of the Veteran's GERD in relation to his more contemporaneous PTSD diagnosis. Based on the above, the Board finds that the June 2021 VA examiner's opinion is both inadequate and did not substantially comply with the January 2021 remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998); Barr v. Nicholson, 21 Vet. App. 303 (2007). Furthermore, the Board finds that based on the new theories of entitlement raised in the October 2021 statement, a remand is required to obtain a supplemental VA opinion. 3. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected PTSD and/or prostate cancer, is remanded. The Veteran asserts that his erectile dysfunction was caused or aggravated by his service-connected PTSD and/or prostate cancer. In a June 2021 VA opinion, the VA examiner opined that the Veteran's erectile dysfunction was less likely than not incurred in or caused by active duty service. In providing a rationale, the June 2021 VA examiner noted that the Veteran's post-service treatment records documented his treatment for low testosterone, otherwise known as hypogonadism, after 2000. Available records also show that the Veteran's erectile dysfunction symptoms began in approximately 1999 to 2000. Citing medical literature, the June 2021 VA examiner discussed how among the risk factors and best predictors of erectile dysfunction, in addition to age, are cardiovascular disease, diabetes mellitus, hypertension, obesity, dyslipidemia, smoking, depression, and medication use. Finding that the Veteran's erectile dysfunction and contributory factors, including age, cardiovascular disease, dyslipidemia, and hypogonadism, began more than 25 years after service, the June 2021 VA examiner found that there was no nexus between the Veteran's erectile dysfunction and service. The Board notes that the June 2021 VA examiner did not include depression among the Veteran's relevant risk factors, even though depression was listed among the best predictors for erectile dysfunction by the cited medical literature. Additionally, the June 2021 VA examiner opined that the Veteran's erectile dysfunction was less likely than not caused or aggravated by his service-connected PTSD and/or prostate cancer. However, the June 2021 VA examiner did not provide an underlying rationale. Accordingly, the Board finds that the opinion is deemed to be conclusory and insufficient for adjudicative purposes. See Nieves-Rodriguez, 22 Vet. App. 295 (2008). Furthermore, in an October 2021 statement, the Veteran's attorney discussed the June 2021 VA examiner's finding that the Veteran's erectile dysfunction was attributed to his low testosterone. The Veteran's attorney noted that the Veteran had provided medical literature discussing how low testosterone can happen in men with advanced prostate cancer. Moreover, the Veteran's attorney noted that the Veteran had submitted several medical articles discussing the relationship between sexual dysfunction and PTSD and prostate cancer. However, the June 2021 VA examiner did not discuss the Veteran's submissions in support of his appeal. Overall, the Board finds that the June 2021 VA examiner's opinion is both inadequate and did not substantially comply with the January 2021 remand instructions. In the January 2021 remand, the Board instructed the VA examiner to provide etiological opinions, which also included a directive to consider the onset of the Veteran's erectile dysfunction in relation to his more contemporaneous PTSD diagnosis. Thus, for all the above reasons, a remand is required to obtain a supplemental VA opinion. See Stegall v. West, 11 Vet. App. 268 (1998); Barr v. Nicholson, 21 Vet. App. 303 (2007). 4. Entitlement to service connection for a cervical spine disability, to include as secondary to service-connected DDD of the lumbar spine, is remanded. In a January 2021 remand, the Board instructed the AOJ to provide an opinion addressing whether the Veteran's cervical spine disability was etiologically related to active duty service. In particular, the Board asked the examiner to accept as valid the Veteran's November 2013 statement that while serving in Vietnam, he suffered the explosive effects of a B-40 rocket and was rolled 15 feet or more, and to state whether a nexus between the Veteran's cervical spine condition and his service is medically consistent with the information provided by the Veteran. In a June 2021 VA examiner's opinion, the VA examiner opined that the Veteran's cervical spine disability, diagnosed as degenerative arthritis and degenerative disc disease, was less likely than not incurred in or caused by active duty service. In providing a rationale, the examiner relied on the findings that the Veteran's service treatment records were silent for a neck or cervical spine condition, including his February 1972 separation examination, that the Veteran's cervical condition was first documented in November 2012 and that his records were otherwise silent regarding neck symptoms. The VA examiner noted that cervical spondylosis, including degenerative disc disease and vertebral facet arthritis, are age related degenerative changes commonly encountered. The Board finds that the June 2021 VA examiner's opinion is inadequate and did not substantially comply with the January 2021 remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998); Barr v. Nicholson, 21 Vet. App. 303 (2007). The June 2021 VA examiner did not specifically address the Veteran's reported in-service injuries from the explosive effects of a B-40 rocket and rolling 15 feet or more. Moreover, in relying on the finding that the Veteran did not have documented reports of neck symptoms or a documented cervical spine condition until 2012, the June 2021 VA examiner did not address a December 2014 lay statement from the Veteran's wife in which she indicated that the Veteran did not seek medical care from VA following service, but his symptoms had progressively worsened. Accordingly, the Board finds that a remand is required to obtain a supplemental VA opinion. 5. Entitlement to service connection for RUE peripheral neuropathy, to include as due to in-service exposure to herbicide agents, and to include as secondary to a cervical spine disability, is remanded. 6. Entitlement to service connection for LUE peripheral neuropathy, to include as due to in-service exposure to herbicide agents, and to include as secondary to a cervical spine disability, is remanded. In a January 2021 remand, the Board instructed the AOJ to obtain opinions addressing whether the Veteran's right and left upper extremity disorders were etiologically related to active duty service or were caused or aggravated by a cervical spine condition. The Board also noted that the examiner should diagnose all right and left upper extremity disorders given during the appeal period, to include diagnoses of moderate to severe sensory greater motor left carpal tunnel syndrome, moderate right sensory carpal tunnel syndrome, and mild ulnar neuropathy suggestive of cubital syndrome with focal slowing across the elbow. In June 2021, the Veteran underwent a VA peripheral nerves examination. The June 2021 VA examiner found that the Veteran did not have a peripheral nerve condition or peripheral neuropathy and that his symptoms of carpal tunnel and cubital tunnel syndrome, which were diagnosed in 2013, had resolved. Following an objective evaluation, the June 2021 VA examiner opined that the Veteran's right and left upper extremity peripheral neuropathy were less likely than not incurred in or caused by active duty service. In providing a rationale, the June 2021 VA examiner noted that the Veteran's 2013 electromyelogram (EMG) found moderate right median neuropathy and severe left carpal tunnel syndrome (median neuropathy) and mild ulnar neuropathy. The Veteran had undergone a left carpal tunnel release in October 2013 and a right carpal tunnel release and right index and middle finger trigger release in January 2016. The June 2021 VA examiner found that the Veteran's symptoms had resolved following his surgical intervention. The June 2021 VA examiner also found that the Veteran did not have documented upper extremity or arm conditions during active duty service, and that the 2013 EMG findings preceding the surgical release were remote. Moreover, the June 2021 VA examiner opined that the Veteran's bilateral upper extremity peripheral neuropathy was less likely than not caused or aggravated by a cervical spine condition. In providing a rationale, the June 2021 VA examiner cited to medical literature and found that the Veteran's ulnar and medial nerve conditions were most commonly incurred due to distal extremity circumstances. Further, the June 2021 relied on the determination that the Veteran's bilateral upper extremity conditions had resolved post surgical intervention and had remained without symptoms despite the cervical condition. Therefore, the June 2021 concluded that there was no nexus between the Veteran's bilateral upper extremity peripheral neuropathy and his cervical spine disability. The Board finds that the June 2021 VA examiner's opinions are both inadequate and do not substantially comply with the January 2021 remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998); Barr v. Nicholson, 21 Vet. App. 303 (2007). First, the June 2021 VA examiner suggests that the 2013 EMG was the first indication of any upper extremity problems. However, according to a January 2009 VA treatment record, the Veteran reported having left wrist and finger pain, and at a November 2012 VA clinic visit, the Veteran reported having chronic bilateral hand or upper extremity numbness or paresthesias over the past six months. Furthermore, according to a December 2014 lay report, the Veteran's wife explained that the Veteran did not seek medical care following service, but he experienced progressively worsening symptoms. Second and most notably, the June 2021 VA examiner repeatedly relied on the finding that the Veteran's bilateral upper extremity symptoms had resolved following his 2013 and 2016 surgical interventions for his left and right upper extremity, respectively. However, a review of the record reveals that VA treatment records in February 2016, July 2017 and February 2020, the Veteran reported symptoms of neuropathy in his hands. Finally, because the Veteran is presumed to have been exposed to herbicide agents based on his Republic of Vietnam service, an opinion addressing whether his bilateral upper extremity peripheral neuropathy is directly related to his herbicide agent exposure is also necessary. Accordingly, the Board finds that a remand is required to obtain a supplemental VA opinion. 7. Entitlement to service connection for RLE sensory polyneuropathy, to include as due to in-service exposure to herbicide agents, and to include as secondary to service-connected DDD of the lumbar spine, is remanded. 8. Entitlement to service connection for LLE sensory polyneuropathy, to include as due to in-service exposure to herbicide agents, and to include as secondary to service-connected shrapnel wounds and/or DDD of the lumbar spine, is remanded. In a January 2021 remand, the Board instructed the AOJ to provide an opinion addressing whether the Veteran's bilateral lower extremity peripheral neuropathy was etiologically related to active duty service or caused or aggravated by his service-connected shrapnel wounds and/or his DDD of the lumbar spine. Specifically, the Board directed the examiner to acknowledge and consider the September 2013 VA examination showing loss of sensation at the lower extremity associated with L5, a part of the spine for which service connection is currently in effect. In addition, the examiner was asked to accept as valid the Veteran's June 2016 statement that his lumbar pain radiated to his buttocks, groin, and down his bilateral legs, and to state whether a nexus between the Veteran's peripheral neuropathy of the right and/or left lower extremity and his service-connected lumbar spine condition is medically consistent with the information provided by the Veteran. In a June 2021 VA opinion, the examiner opined that the Veteran's bilateral lower extremity peripheral neuropathy was less likely than not incurred in or caused by his active duty service. In providing a rationale, the June 2021 VA examiner found that 2013 EMG findings were consistent with polyneuropathy. The June 2021 VA examiner found that the Veteran's service treatment records, including his February 1972 separation examination, were silent for a lower extremity condition. In addressing the causation prong for secondary service connection, the June 2021 VA examiner provided an unfavorable nexus opinion related to the Veteran's service-connected shrapnel wounds, however, the June 2021 VA examiner used the incorrect legal standard. In addressing the aggravation prong for secondary service connection, the June 2021 VA examiner opined that the Veteran's right and left peripheral neuropathy were less likely than not aggravated by his service-connected shrapnel wounds. In providing a rationale, the June 2021 VA examiner found that the subcutaneous shrapnel of the right knee and posterior thigh is independent and noncontributory to the degenerative disc and lumbar facet spondylosis. The June 2021 VA examiner found that the Veteran's lumbar condition was a consequence of advancing age and was not likely present during military service. Finally, the June 2021 VA examiner opined that the Veteran's right and left peripheral neuropathy were less likely than not caused or aggravated by his service-connected DDD of the lumbar spine. In providing a rationale, the June 2021 VA examiner relied on the sole finding that the Veteran's sensory polyneuropathy was independent of the lumbar condition. The AOJ requested an addendum opinion to address the causation prong of secondary service connection. However, in an August 2021 VA opinion, the VA examiner continued to use the incorrect legal standard. The Board finds that the June 2021 VA examiner's opinion and subsequent August 2021 VA addendum opinion are both inadequate and do not substantially comply with the January 2021 remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998); Barr v. Nicholson, 21 Vet. App. 303 (2007). First, the June 2021 and August 2021 VA examiners did not address the September 2013 VA examination finding of decreased sensory examination results at L5 or the September 2016 private treatment record documenting lumbar spine pain radiating into his buttocks, groin, and down the bilateral legs, as directed by the January 2021 remand. Second, the June 2021 and August 2021 VA opinions both used the incorrect legal standard for the causation prong regarding his service-connected shrapnel wounds. Third, the June 2021 VA examiner's rationale for the aggravation prong did not discuss the relationship of the Veteran's shrapnel wounds and his bilateral lower extremity sensory polyneuropathy. Rather, the rationale focused more on the relationship between the Veteran's lumbar spine disability and his shrapnel wounds. Fourth, the June 2021 VA examiner provided no rationale associated with the secondary service connection opinions regarding his service-connected DDD of the lumbar spine. Finally, neither the June 2021 or August 2021 VA examiners addressed whether the Veteran's bilateral lower extremity sensory polyneuropathy was directly caused by his presumed exposure to herbicide agents. Accordingly, a remand is required to obtain a supplemental VA opinion. 9. Entitlement to an extension of temporary total evaluation because of surgical treatment requiring convalescence following spinal fusion is remanded. The Veteran was assigned a temporary total evaluation following his April 2018 spinal fusion at a private facility for a convalescent period of three months. The Veteran is seeking an extension of that temporary total evaluation. A review of the records reveals that VA received treatment records in 2018 and 2019 from MidMichigan Health, the facility where the Veteran underwent his spinal fusion, and Dr. M.A., the neurosurgeon who performed the surgery, and that those records had been scanned into VistA Imaging. Those MidMichigan Health and Dr. M.A. treatment records have not been associated with the record and are unavailable for review. Because these non-VA provider treatment records may provide relevant information to substantiate the Veteran's claim for an extension of his temporary total evaluation, a remand is required to obtain those records and associate them with the record. 10. Entitlement to an extension of SMC at the housebound rate under 38 U.S.C. § 1114(s) is remanded. The Veteran is currently receiving SMC at the housebound rate under 38 U.S.C. § 1114(s) from October 3, 2014 to December 1, 2015, from April 20, 2018 to August 1, 2018, and from August 9, 2018 to the present. The Veteran is seeking an extension of SMC based on the housebound criteria being met. However, the claim for an extension of SMC at the housebound rate may be affected by the outcome of the service connection claims for a lung disability, GERD, erectile dysfunction, cervical spine disability, bilateral upper extremity peripheral neuropathy, and bilateral lower extremity sensory polyneuropathy. Thus, it would be premature to adjudicate the claim for an extension for SMC at the housebound rate until the service connection claims have been considered. Therefore, the issues are inextricably intertwined, and the claim for an extension of SMC at the housebound rate under 38 U.S.C. § 1114(s) must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following actions: 1. Obtain all the outstanding treatment records for the Veteran's lung disability, GERD, erectile dysfunction, cervical spine disability, bilateral upper extremity peripheral neuropathy, and bilateral lower extremity sensory polyneuropathy that are not currently of record, to include VA treatment records from Saginaw VA Medical Center since February 2021. For the Veteran's lung disability, offer the Veteran the opportunity to submit treatment records from Michigan State University dated in the 1990's, to include any respiratory testing results. 2. Obtain the 2018 and 2019 MidMichigan Health and Dr. M.A. treatment records that were scanned into VistA Imaging for the Veteran's DDD of the lumbar spine following his spinal fusion as identified in 2018 and 2019 VA treatment records. 3. Schedule the Veteran for a VA examination by an appropriately qualified clinician (M.D.) to determine the nature and etiology of any lung disability. The examiner must respond to the following: (a.) Does the Veteran have a current diagnosis for a lung disability? If so, please identify. (b.) For each diagnosis, is it at least as likely as not (50 percent or greater probability) that the Veteran's lung disability had its onset in, was caused by, or is otherwise etiologically related to active duty service, to include his reported in-service asbestos exposure? In providing the above opinions, the examiner must address the April 2018 PFT which identified findings suggestive of asthma. The examiner must address all of the Veteran's reports of respiratory problems, including dyspnea. In evaluating whether the Veteran has a current lung disability, the examiner must not confine the evaluation to lung cancer or asbestosis. Finally, the examiner must address the Veteran's reports of exposure to asbestos during active duty service. A complete rationale with discussion of medical literature for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. 4. Obtain an addendum opinion from an appropriately qualified clinician (M.D.) to determine the nature and etiology of the Veteran's GERD. The examiner must respond to the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's GERD had its onset in, was caused by, or is otherwise etiologically related to active duty service? (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's GERD was caused by his service-connected PTSD? (c.) Is it at least as likely as not that the Veteran's GERD was aggravated beyond its natural progression by his service-connected PTSD? In providing the above opinions, the examiner cannot only rely on his or her review of medical literature without specifically addressing the medical literature provided by the Veteran supporting his claim of a relationship between GERD and PTSD. To the extent that the examiner finds that the Veteran's alcohol use caused or contributed to his development of GERD, the examiner should address the Veteran's assertions that his alcohol consumption was due to him trying to relieve his PTSD symptoms. Finally, the examiner must consider not only the onset of the Veteran's GERD in relation to the time passed since his separation from service but also in relation to his more contemporaneous PTSD diagnosis. Also, regarding obesity as an "intermediate step," the examiner is asked to respond to the following: (d.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's service-connected PTSD, right knee disability, DDD of the lumbar spine, left knee strain, and/or left ankle osteoarthritis caused the Veteran to become obese? (e.) If the answer to the above is yes, was the obesity a substantial factor in causing or aggravating the Veteran's GERD? (f.) If the answer to the above is yes, would GERD not have occurred but for the obesity caused by the Veteran's service-connected PTSD, right knee disability, DDD of the lumbar spine, left knee strain, and/or left ankle osteoarthritis? A complete rationale with discussion of medical literature for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. 5. Obtain an addendum opinion from an appropriately qualified clinician (M.D.) to determine the nature and etiology of the Veteran's erectile dysfunction. The examiner must respond to the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's erectile dysfunction was caused by his service-connected PTSD and/or prostate cancer? (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's erectile dysfunction was aggravated beyond its natural progression by his service-connected PTSD and/or prostate cancer? In providing the above opinions, the examiner cannot only rely on his or her review of medical literature without specifically addressing the medical literature provided by the Veteran supporting his claim of a relationship between sexual dysfunction and PTSD and/or prostate cancer, to include the discussion of how low testosterone can happen in men with advanced prostate cancer. The examiner must also address the June 2021 VA examiner's citation of medical literature discussing the various risk factors and best predictors for erectile dysfunction, which included depression. Finally, the examiner must consider not only the onset of the Veteran's erectile dysfunction in relation to the time passed since his separation from service but also in relation to his more contemporaneous PTSD diagnosis. A complete rationale with discussion of medical literature for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. 6. Obtain an addendum opinion from an appropriately qualified clinician (M.D.) to determine the nature and etiology of the Veteran's cervical spine disability. The examiner should respond to the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's cervical spine disability had its onset in, was caused by, or is otherwise etiologically related to active duty service? In providing the above opinion, the examiner is asked to accept as valid the Veteran's November 2013 statement that, while serving in Vietnam, he suffered the explosive effects of a B-40 rocket and was rolled 15 feet or more, and state whether a nexus between the Veteran's cervical spine condition and his service is medically consistent with the information provided by the Veteran. The examiner must not rely on the finding that the Veteran did not have documented or reported neck problems during service without also specifically addressing the Veteran's reported in-service explosive event. Further, the examiner must address the December 2014 lay statement from the Veteran's wife indicating that the Veteran delayed seeking treatment following service, but he experienced progressively worsening symptoms. A complete rationale with discussion of medical literature for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. 7. Obtain an addendum opinion from an appropriately qualified clinician (M.D.) to determine the nature and etiology of the Veteran's bilateral upper extremity peripheral neuropathy. The examiner must respond to the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's right and/or left peripheral neuropathy had its onset in, was caused by, or is otherwise etiologically related to active duty service, to include his presumed exposure to herbicide agents? (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's right and/or left peripheral neuropathy was caused by his cervical spine disability? (c.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's right and/or left peripheral neuropathy was aggravated by his cervical spine disability? In providing the above opinions, the examiner must discuss all diagnoses of the right and left upper extremity disorders during the appeal period, to include diagnoses of moderate to severe sensory greater than motor left carpal tunnel syndrome, moderate right sensory carpal tunnel syndrome, and mild ulnar neuropathy suggestive of cubital tunnel syndrome with focal slowing across the elbow. The examiner must address the Veteran's VA treatment records in 2016, 2017, and 2020 documenting reports of neuropathy in the hands. In addressing the Veteran's exposure to herbicide agents, the examiner must provide an opinion regarding whether his right and/or left upper extremity peripheral neuropathy are directly caused by such exposure. The examiner must not rely on the finding that the Veteran did not have documented or reported upper extremity or arm problems until many years after service without also specifically addressing the December 2014 lay statement from the Veteran's wife indicating that the Veteran delayed seeking treatment following service, but he experienced progressively worsening symptoms. A complete rationale with discussion of medical literature for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. 8. Obtain an addendum opinion by an appropriately qualified clinician (M.D.) to determine the nature and etiology of the Veteran's right and left sensory polyneuropathy. The examiner must respond to the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's right and/or left sensory polyneuropathy had its onset in, was caused by, or is otherwise etiologically related to active duty service, to include his presumed exposure to herbicide agents? (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's right and/or left sensory polyneuropathy was caused by his service-connected shrapnel wounds? (c.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's right and/or left sensory polyneuropathy was aggravated beyond its natural progression by his service-connected shrapnel wounds? (d.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's right and/or left sensory polyneuropathy was caused by his service-connected DDD of the lumbar spine? (e.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's right and/or left sensory polyneuropathy was aggravated beyond its natural progression by his service-connected DDD of the lumbar spine? In providing the above opinions, the examiner must address the September 2013 VA examination showing loss of sensation at the lower extremity associated with L5, a part of the spine for which service connection is currently in effect. The examiner must also accept as valid the Veteran's June 2016 statement that his lumbar pain radiated to his buttocks, groin, and down his bilateral legs, and state whether a nexus between the Veteran's sensory polyneuropathy of the right and/or left lower extremity and his service-connected lumbar spine condition is medically consistent with the information provided by the Veteran. In addressing the Veteran's exposure to herbicide agents, the examiner must provide an opinion regarding whether his right and/or left upper extremity peripheral neuropathy are directly caused by such exposure. A complete rationale with discussion of medical literature for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. 9. To avoid another remand, the AOJ must review the requested development and ensure that the Board's specific instructions have been completed in full. If any development is found to be inadequate, it must be returned to the providing examiner for corrective action. If such corrective action is not requested, then the Board will be required to return the case to the AOJ for substantial compliance with its remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998). 10. After ensuring the above development has been completed, readjudicate the issues on appeal, to include the inextricably intertwined issue of entitlement to an extension of SMC at the housebound rate under 38 U.S.C. § 1114(s). If the benefits sought on appeal are not granted to the Veteran's satisfaction, send the Veteran and his representative a SSOC and provide an opportunity to respond. Then, return the case to the Board for further appellate review. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Journet Shaw, 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.