Citation Nr: 21066255 Decision Date: 10/29/21 Archive Date: 10/29/21 DOCKET NO. 16-06 048 DATE: October 29, 2021 REMANDED Entitlement to service connection for a neurological disorder, to include Parkinson's Disease and cerebral vascular disease, is remanded. REASONS FOR REMAND At the outset, the Board wants to provide clarification as to the examination referenced in the November 2020 remand. The examination was signed January 2020 but performed December 2019. As such, any previous mention of a January 2020 examination was in error and should have read December 2019. The Veteran testified before the undersigned Veterans Law Judge in a February 2019 video conference hearing. A transcript of that hearing has been associated with the file. The Board remanded the matters twice, in May 2019 and November 2020. Frustratingly, the Board finds that there has not been substantial compliance of the remand directives and therefore another remand is required. See Stegall v. West, 11 Vet. App. 268 (1998). The remand directives required an examiner to provide clarification as to what the current diagnosis or diagnoses are with respect to any neurological disorders. A VA neurologist provided opinions in January 2021 and March 2021. A Medical Opinion Disability Benefits Questionnaire (DBQ) was performed in January 2021. However, the report does not refer as to what kind or kinds of neurological disorder(s) the Veteran has or has had at any time during the appeal period. In the March 2021 addendum opinion, the examiner concluded that the current diagnosis is vascular occlusive disease. Although an in-person examination was left to the discretion of the examiner, an in-person examination was not performed, and the examiner failed to address how it is she arrived at the conclusion that the current diagnosis is vascular occlusive disease. Additionally, the remand directives required clarification and the examiner failed to discuss the previous diagnoses in the record. Additionally, the opinion provided as to the etiology of the Veteran's neurological disorder is inadequate. The examiner opined that the vascular occlusive disease is not related to service. The rationale was simply stated as medical literature has not proven jet fuel to be the cause of this condition and that she agreed with the December 2019 VA examiner. In the November 2020 remand, the Board provided great detail as to the errors, concerns, and reasons why the December 2019 VA examination report was inadequate. As such, it reads as problematic that the VA examiner that provided the January 2021 DBQ report and the March 2021 addendum report would simply defer to the December 2019 VA opinion. Given the current opinions of record and the lack of clarity of what neurological disorders the Veteran has, the Board finds that an in-person examination will assist in providing information necessary for this service connection claim. For all these reasons the Board finds that an additional remand is needed as it is still unclear as to what the current diagnosis is, or diagnoses are in relation to the Veteran's claimed degenerative neurological disorder and adequate medical opinions need to be part of the record. Lastly, a review of the record shows that the Veteran receives private treatment for his neurological disorder from a Dr. F. and a Dr. S. See March 2015 VA treatment records. There are treatment records from a Dr. F in evidence. As the matter is being remanded, additional efforts should be made to obtain any outstanding private treatment records, to include those from Dr. S. The matter is REMANDED for the following action: 1. Obtain and associate with the Veteran's claims file any outstanding VA treatment records documenting treatment for Parkinson's Disease, parkinsonian, vascular disease, or any neurological disorder. The Veteran should also be afforded the opportunity to identify and/or submit any outstanding private treatment records, to include treatment records from Dr. S. 2. Schedule an appropriate VA examination to determine the nature and etiology of the Veteran's neurological disorder, preferably with an examiner who has not been involved in this case previously. The claims file and a copy of this remand must be made available to the examiner for review. This examination can be in person or virtual. The examiner should review the claim file (including this remand) and note such review was conducted. The examiner should identify all current neurological disorders, to include Parkinson's Disease, found at any time during the appeal period (from April 2015). If any previously diagnosed neurological disorder is not found on examination, the examiner must address the prior diagnoses of record and indicate whether they may have resolved or been misdiagnosed. The examiner should be directed to elicit a complete history from the Veteran, and to account for his reported history in the opinion. Following review of the claims file and examination of the Veteran, the examiner should provide opinions that respond to the following: (a.) Whether it is at least as likely as not (i.e., probability of 50 percent) that any neurological disorder(s), to include Parkinson's Disease, manifested during active service; or is otherwise related to an event, injury, or disease incurred during active service, to include his presumed exposure jet fuel. For the purposes of this opinion the examiner is to assume that the Veteran was exposed to jet fuel in service. If any previously diagnosed disability is not found on examination, the examiner should address the prior diagnoses of record and indicate whether they may have resolved or been misdiagnosed. (b.) Specifically, the examiner is requested to comment and account for in his/her opinion the private treatment record dated October 2014 authored by Dr. F. wherein the examiner stated, "parkinsonism, pbly on vascular basis, stage 2.0" and "I think pt has vascular parkinsonism and vascular based MCI." 1. The examiner should explicitly state whether this diagnosis is accurate, whether it should be considered resolved, or whether it is a misdiagnosis. This record is located at: VBMS, document labeled Medical Treatment Record-Non-Government Facility, receipt date listed April 6, 2015, pg. 2 of 4. (c.) Specifically, the examiner is requested to comment and account for in his/her opinion the VA record dated March 2015 wherein the examiner stated there are no real signs of Parkinson's Disease, and that she assured the Veteran that he does not have Parkinson's Disease, but that his symptoms may be attributed to vascular disease/multiple strokes in the past. 1. The examiner should explicitly state whether this diagnosis is accurate, whether it should be considered resolved, or whether it is a misdiagnosis. This record is located at: VBMS, document labeled CAPRI, receipt date listed March 18, 2021, pg. 12 of 23. (d.) Specifically, the examiner is requested to comment and account for in his/her opinion the VA physical therapy treatment record dated April 2015 wherein the examiner concluded not only did the Veteran have Parkinson's Disease, but that this diagnosis was made 5 years prior. 1. The examiner should explicitly state whether this diagnosis is accurate, whether it should be considered resolved, or whether it is a misdiagnosis. This record is located at: VBMS, document labeled CAPRI, receipt date listed June 12, 2015, pg. 1 of 6. (e.) Specifically, the examiner is requested to comment and account for in his/her opinion the VA treatment record dated October 2015 wherein the neurologist diagnosed parkinsonism, agreeing with the diagnosis of vascular parkinsonism which appears mild/moderate, left sided. 1. The examiner should explicitly state whether this diagnosis is accurate, whether it should be considered resolved, or whether it is a misdiagnosis. This record is located at: VBMS, document labeled Medical Treatment Record-Government Facility, receipt date listed January 26, 2016, pg. 7 of 36. (f.) Specifically, the examiner is requested to comment and account for in his/her opinion the December 2019 VA examination report wherein the examiner indicated a 2011 diagnosis of Parkinson's Disease and concluded that the Veteran's Parkinson's Disease is vascular and not organic. 1. The examiner should explicitly state whether this diagnosis is accurate, whether it should be considered resolved, or whether it is a misdiagnosis. This report is located at: VBMS, document labeled C&P Exam, receipt date listed January 8, 2020, pg. 1 of 4, and at VBMS, document labeled C&P Exam, receipt date listed January 8, 2020, pg. 1 of 3. (g.) Specifically, the examiner is requested to comment and account for in his/her opinion the November 2020 private treatment record wherein the examiner diagnosed parkinsonism, "pbly on vascular basis" and stated that he told the Veteran "he had vascular parkinsonism as I had not noted the above impression from July 22, 2020. I am unsure of dx." 1. The examiner should explicitly state whether this diagnosis is accurate, or should be considered resolved, or whether it is a misdiagnosis. This record is located at: VBMS, document labeled Medical Treatment Record-Non-Government Facility, receipt date listed December 11, 2020, pg. 5 of 11. The examiner is advised that the Veteran is competent to report observable symptoms. The examiner is further advised that the mere absence of treatment records is not wholly dispositive as to whether he had ongoing problems related to a neurological disorder since service, or as to whether the reported symptoms are credible. Any opinion offered must be supported by a complete rationale. If the clinician feels that the requested opinion cannot be rendered without resorting to speculation, he or she must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required), or the examiner does not have the needed knowledge or training). 3. The AOJ should ensure that the opinions conform with the remand directives. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Talamantes, 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.