Citation Nr: 21066937 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 17-64 835 DATE: November 2, 2021 REMANDED Entitlement to service connection for a stomach disorder, to include as secondary to hemorrhoids with perirectal abscess, is remanded. Entitlement to service connection for right lower extremity peripheral neuropathy, to include as secondary to service-connected hemorrhoids with perirectal abscess, is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1982 to January 1986. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In December 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the record. In March 2020, the Board remanded the issues on appeal and also remanded the issue of an increased rating for service-connected genital herpes. See BVA Decision (March 2020). In September 2020, the RO assigned a 60 percent evaluation for genital herpes, effective the entire appeal period. See Rating Decision (September 2020). The RO notified the Veteran that this was a full grant of the issue on appeal. See Rating Decision (September 2020). This is because that is the maximum rating available for this disability under the General Rating Formula for the Skin. See 38 C.F.R. § 4.118. No argument to the contrary was received from the Veteran or his representative; the Board finds that the issue is no longer on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). 1. Entitlement to service connection for a stomach disorder, to include as secondary to hemorrhoids with perirectal abscess, is remanded. The Veteran contends that his stomach disorder is secondary to his service-connected hemorrhoids with perirectal abscess. See Hearing Transcript (December 2019); Form 9 (December 2017); NOD (April 2016). The Board finds that remand is warranted to obtain an adequate examination. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A disability which resolves during the appeal period is subject to service connection. McClain v. Nicholson, 21 Vet. App. 319 (2007). In the March 2020 remand, the Board directed that the examiner provide an opinion whether each stomach disorder was due to or aggravated by service-connected hemorrhoids and perirectal abscess. See BVA Decision (March 2020). Here, there is a diagnosis of IBS. See CAPRI (May 2021). In 2014, gastritis was diagnosed via endoscopy. See CAPRI (April 2019); CAPRI (May 2021). In 2016, an endoscopy was normal. See CAPRI (April 2019); CAPRI (May 2021). A 2017 VA record noted altered GI function related to the diagnoses of IBS and chronic gastritis. See CAPRI (April 2019). An April 2021 VA record noted an intestinal motility disorder. See CAPRI (May 2021). A June 2020 VA medical opinion was obtained. Regarding IBS, the VA examiner opined that there was no nexus between the service-connected hemorrhoids and the IBS, noting that the literature does not support such a finding. See C&P Exam (July 2020). The examiner also found that the service-connected disability did not aggravate or worsen the IBS. See C&P Exam (July 2020). The examiner did not provide any support for the secondary aggravation opinion and did not indicate what literature they reviewed to support the secondary causation opinion. Regarding gastritis, no opinion was provided because the examiner found there was no current gastritis. See C&P Exam (July 2020). The examiner noted that although the literature supports that gastritis can be caused by medications taken for hemorrhoids, a January 2016 endoscopy and biopsy were normal. See C&P Exam (July 2020). But service connection can be granted if a disability exists during part of the appeal period; here, the Veteran filed his claim in January 2016, gastritis was still diagnosed in early 2016, and his gastrointestinal complaints have continued. See VA 21-526 Veterans Application for Compensation or Pension (January 2016); CAPRI (May 2021). Finally, the relevant diagnoses are unclear. Thus, remand is required for clarification. 2. Entitlement to service connection for right lower extremity peripheral neuropathy, to include as secondary to service-connected hemorrhoids with perirectal abscess, is remanded. The Veteran contends that his right lower extremity peripheral neuropathy is due to service-connected hemorrhoids with abscess, as it was a post-operative complication from his abscess surgeries. See Hearing Transcript (December 2019). He has reported that he did not have pain or neuropathy in the right lower extremity until after his 5 surgeries for his perirectal abscess. See NOD (July 2015). The evidence of record has also suggested that there may be right lower extremity cold injury residuals. See C&P Exam (July 2020). The Board finds that remand is warranted to obtain a VA examination and addendum opinion. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. The crux of this appeal is whether there was a cold injury during service and whether there are any current residuals of such an injury. A January 1985 service treatment record (STR) notes rule out immersion foot. The toes were cold to the touch and treatment was to observe. See STR (December 2011). The next day, the Veteran was seen for follow-up and the assessment was probable non-freezing injury. See STR (December 2011). One month later, the Veteran reported aching pain in both feet and the assessment was cold feet. See STR (December 2011). In a December 1985 STR, the Veteran requested a cold weather profile due to possible cold weather injury in January 1985. See STR Medical Photocopy (February 2013). It was noted that there was frostnip while in Germany, but there had been no sequelae. The assessment was cold weather exposure. See STR Medical Photocopy (February 2013). A June 2010 VA examiner presumed there was a current RLE neuropathy and provided a negative nexus opinion that was later found inadequate. See VA Examination (July 2010); BVA Decision (March 2020). A February 2013 VA examination was conducted without review of the claims file and noted a subjective sensory only peripheral neuropathy, bilateral foot cold injury residuals. See VA Examination (February 2013). Findings upon examination included fungal toenails, hypopigmentation of the soles of the foot, loss of hair on the dorsum of the foot, decreased vibratory sensation, and sciatic nerve mild incomplete paralysis. See C&P Exam (February 2013). The examiner provided a positive nexus opinion that was found inadequate as it was done without review of the Veteran's claims file or relevant records. See C&P Exam (February 2013); BVA Decision (March 2020). A March 2013 addendum opinion was obtained upon review of the claims file. See C&P Exam (April 2013). The examiner found there was no cold injury, noting that a 2011 most VA record found there was no evidence of neuropathy and a 2013 x-ray of the feet found no evidence of a bone or joint condition consistent with prior cold injury. See C&P Exam (April 2013). The examiner provided a negative nexus opinion for cold injury, noting the post-service medical records did not indicate peripheral neuropathy. See C&P Exam (April 2013). The examiner did not, however, provide a secondary service connection opinion. In a June 2020 VA medical opinion, the examiner opined that there was no nexus between any cold injury and a current right lower extremity disorder. See C&P Exam (June 2020). The examiner acknowledged the Veteran's lay statements of symptoms, and that medical literature supports that numbness, paresthesias, and/or sensory deficits can occur as a long-term complication of a cold injury. The examiner then reasoned there was no nexus because there are multiple possible etiologies for a unilateral neuropathy of the lower extremity, 2009 diagnostic test findings were not supportive and the Veteran terminated further testing, and the claims file did not show evidence of long-term sequelae including loss of toenails, hyperhidrosis or anhidrosis, muscle atrophy, bone abnormalities, vascular insufficiency, or skin changes. See C&P Exam (June 2020). The examiner did not, however, address the 2013 findings of reduced vibratory sensation and potential skin changes and whether those support the presence of cold injury residuals. Regarding secondary service connection, the examiner found that the RLE neuropathy is separate and unrelated to hemorrhoids as nerve damage from an anal/rectal procedure can result in urinary and/or sexual dysfunction, but not a lower extremity peripheral neuropathy. The examiner found there was no evidence to support aggravation beyond natural progression by the service-connected hemorrhoids with perirectal abscess. See C&P Exam (July 2020). The examiner provided no supporting explanation for the aggravation opinion. Accordingly, addendum opinions must be obtained. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from March 2021 to the Present. 2. Obtain an addendum opinion regarding the etiology of the gastrointestinal disorders, to include IBS, gastritis, and an intestinal motility disorder, from a VA examiner. If an examination is deemed necessary, it shall be provided. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptoms consistent with the diagnosed gastrointestinal disabilities. The opinion should, among other things, include a discussion of the Veteran's documented history and assertions. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). The clinician should provide the following opinions, with supporting rationale: (a) What are the Veteran's relevant stomach diagnoses? If IBS, gastritis, or intestinal motility disorder are not diagnosed, please address the prior diagnoses of record. (b) Whether the Veteran's stomach disorder, to include IBS, gastritis, or an intestinal motility disorder, are at least as likely as not (1) caused by service-connected hemorrhoids with perirectal abscess, or (2) aggravated beyond natural progression by service-connected hemorrhoids with perirectal abscess, to include medications take for hemorrhoids. Consider the following: (a) VA treatment records diagnosing IBS, gastritis, and intestinal motility disorder; and (b) the June 2020 VA examination. Explain. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): If any medical history is rejected, a complete explanation is required. 3. Obtain an addendum opinion regarding the etiology of a right lower extremity disorder, from a VA examiner. If an examination is deemed necessary, it shall be provided. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptoms consistent with a right lower extremity disorder. The opinion should, among other things, include a discussion of the Veteran's documented history and assertions. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). The clinician should provide the following opinions, with supporting rationale: (a) What are the Veteran's relevant right lower extremity diagnoses? If peripheral neuropathy is not diagnosed, please address the prior diagnoses of record and any other relevant evidence. (b) Whether any right lower extremity disorder, including peripheral neuropathy if diagnosed, at least as likely as not (1) had its onset in service, or (2) is otherwise related to an in-service injury, event, or disease, to include the noted cold exposure during service. (c) Whether any right lower extremity disorder, including peripheral neuropathy if diagnosed, is at least as likely as not (1) caused by service-connected hemorrhoids with perirectal abscess, or (2) aggravated beyond its natural progression by service-connected hemorrhoids with perirectal abscess, to include the multiple surgeries undertaken to address the abscess. Consider the following: (a) the 1985 STRs that indicate cold exposure during service; (b) the Veteran's lay statements of symptoms; (c) the 2010 VA examination and opinion; (d) the February and March 2013 VA examination and opinions, including the findings in February 2013 of fungal toenails, hypopigmentation of the soles of the foot, loss of hair on the dorsum of the foot, decreased vibratory sensation, and sciatic nerve mild incomplete paralysis; (e) the 2020 VA medical opinion; and (f) relevant VA medical records, including a December 2009 EMG that was normal, December 2009 NCS testing that was terminated due to discomfort, a May 2011 record in which the clinician noted that the testing and clinical examination did not suggest neuropathy, a February 2015 x-ray of the right foot that showed no abnormality, and the Veteran's reports of leg pain in 2011, 2013, and 2021. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): If any medical history is rejected, a complete explanation is required. 4. Ensure that the medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 5. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.M., 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.