Citation Nr: 21071178 Decision Date: 11/30/21 Archive Date: 11/29/21 DOCKET NO. 18-27 804 DATE: November 30, 2021 REMANDED Entitlement to service connection for venous insufficiency, to include as secondary to service-connected hypertension is remanded. Entitlement to service connection for lymphedema, to include as secondary to service-connected hypertension is remanded. Entitlement to a total disability rating on the basis of individual unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran had honorable active duty service with the United States Army from March 1987 to May 1991. This matter is before the Board on appeal from an April 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In July 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing has been associated with the Veteran's electronic claims file. In October 2020 the Board remanded the claims for development. In February 2021, the Veteran was afforded a new VA examination. After a supplemental statement of the case (SSOC), the claims are back before the Board. 1. Entitlement to service connection for venous insufficiency is remanded. See section 2 below. 2. Entitlement to service connection for lymphedema is remanded. Although further delay is regrettable, a remand is necessary for an adequate VA opinion. When an opinion does not express the right degree of certainty, does not provide a rationale, is conclusory, does not consider all of the relevant evidence of record including lay statements, or does not consider all raised theories of entitlement then the examination is inadequate. Steff v. Nicholson, 21 Vet. App. 120 (2007); Bloom v. West, 12 Vet. App. 185, 187 (1999); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Combee v. Brown, 34 F.3rd1039, 1043-44 (Fed. Cir. 1994). The Veteran contends that her service-connected impairments have caused or aggravated her venous insufficiency and lymphedema. In particular, the Veteran is service connected for hypertension. She testified at the hearing that she believed hypertension caused her to develop venous hypertension and that venous hypertension caused or aggravated her lymphedema or venous insufficiency. See Hearing Transcript received July 2020. On review of the February 2021 VA examinations and opinions, the Board finds that the examiner did not provide a sufficient rationale as to why these impairments were not caused by or aggravated by the Veteran's hypertension. The examiner did not sufficiently discuss relevant medical records or provide a rationale as to why the Veteran's hypertension had not aggravated these conditions. The February 2021 VA examiner opined that lymphedema is not associated with hypertension and that hypertension is not listed among the risk factors for lymphedema. See C&P Exams received February 2021. Similarly, as to venous insufficiency, the examiner opined that venous insufficiency was not associated with hypertension and not listed as a risk factor. Id. Within the rationale for the negative nexus opinion for lymphedema, the examiner stated that the Veteran had not had imaging to include but not limited to lymphoscintigraphy or MR-lymphangiography to objectively assess or document her lymphedema. Id. While the February 2021 examiner stated that there was no associations between these conditions and the Veteran's service-connected hypertension, the Board noted that in October 2014, the Veteran's primary care provider wrote a letter stating that the Veteran's hypertension caused fluid retention and edema which caused her pain in her extremities. See Buddy/Lay Statement received October 2014. Additionally, in March 11, 2019, the Veteran had a consultation with a cardiologist. See CAPRI received April 2019. The assessment or plan for lymphedema stated that "amlodipine for hypertension may be contributing." Id. Specifically, the October 2014 and March 2019 evidence was noted by the Veteran's representative during the July 2020 hearing and not properly addressed by the February 2021 inadequate medical opinions. Thus, the February 2021 VA medical opinions are inadequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (holding that when the VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate); see also El-Amin v. Shinseki, 26 Vet. App. 136 (2013) (holding that an opinion for secondary service connection is inadequate when it does not address or rule out the possibility that the service-connected impairment aggravated to some degree the claimant's non service-connected impairment). Moreover, if objective testing is needed to properly assess whether the Veteran's service-connected hypertension has caused or aggravated the Veteran's venous insufficiency or lymphedema, then such testing should be performed. Considering all the above, a remand is needed to correct these duty-to-assist deficiencies. 3. Entitlement to TDIU is remanded. The claim of entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU) is remanded. As the Veteran is asserting entitlement to TDIU, the Board finds that this issue is inextricably intertwined with the resolution of the remanded issues. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to defer the claim on appeal pending the adjudication of the inextricably intertwined claim. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, this issue is remanded for readjudication following evidentiary development. The matters are REMANDED for the following action: This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38U.S.C. §7107(a)(2). 1. Identify and obtain any outstanding VA and private treatment records that are not already associated with the claims file. If any record identified cannot be obtained, the Veteran and her representative should be notified of this in writing, to include all efforts taken by VA to attempt to obtain any such record. The Veteran should also be offered the option to provide any such record herself. 2. Then, request a VA medical opinion, by a medical expert with the appropriate training and expertise to determine the nature and etiology of the Veteran's venous insufficiency and lymphedema. The Veteran's claim file and a copy of this remand should be provided to the examiner and the examination report should reflect that these items were reviewed. Following review of the claims file, the examiner should answer the following questions: (a.) Is it at least as likely as not (50 percent probability or greater) that the Veteran's venous insufficiency is etiologically related to or caused by her service? (b.) Is it at least as likely as not (50 percent probability or greater) that the Veteran's lymphedema is etiologically related to or caused by her service? (c.) Then also answer, is it at least as likely as not (50 percent probability or greater) that the Veteran's venous insufficiency was either: 1. caused by a service-connected disability including, specifically hypertension, OR; 2. aggravated by (i.e., worsened beyond the normal progression of the disease) the Veteran's service-connected disability including, specifically hypertension? In addressing whether any of the Veteran's service-connected disabilities, including, specifically hypertension, was a source of aggravation of the Veteran's venous insufficiency the examiner must attempt to establish a baseline level of severity of the venous insufficiency prior to aggravation by the service-connected disability, if any can be determined. (d.) Then also answer, is it at least as likely as not (50 percent probability or greater) that the Veteran's lymphedema was either: 1. caused by a service-connected disability including, specifically hypertension, OR; 2. aggravated by (i.e., worsened beyond the normal progression of the disease) the Veteran's service-connected disability including, specifically hypertension? In addressing whether any of the Veteran's service-connected disabilities, including, specifically hypertension, was a source of aggravation of the Veteran's lymphedema the examiner must attempt to establish a baseline level of severity of the lymphedema prior to aggravation by the service-connected disability, if any can be determined? (e.) When addressing the opinions for venous insufficiency and lymphedema above, please consider and discuss: that in October 2014, the Veteran's primary care provider wrote a letter stating that the Veteran's hypertension caused fluid retention and edema which caused her pain in her extremities; and in March 11, 2019, a VA cardiologist's consultation suggested that the medication amlodipine for hypertension may be contributing to the Veteran's lymphedema. See CAPRI received April 2019; Buddy/Lay Statement received October 2014. 3. A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what additional evidence, if any, would allow for a more definitive opinion. 4. If any benefit sought on appeal is not granted, the Veteran and her representative should be provided a Supplemental Statement of the Case (SSOC) and afforded the requisite opportunity to respond before the case is returned to the Board. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Associate Counsel, C. Parnell 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.