Citation Nr: A21018968 Decision Date: 11/29/21 Archive Date: 11/29/21 DOCKET NO. 190805-18911 DATE: November 29, 2021 REMANDED Entitlement to service connection for carpal tunnel syndrome of the right upper extremity is remanded. Entitlement to service connection for carpal tunnel syndrome of the left upper extremity is remanded. Entitlement to a rating in excess of 20 percent for a lumbar spine disability is remanded. Entitlement to an initial rating in excess of 30 percent for PTSD is remanded. REASONS FOR REMAND The Veteran served active duty in the United States Army from August 1989 to January 2004. These matters are before the Board of Veterans' Appeals (Board) on appeal from a June 2019 rating decision by the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). The Veteran filed a timely appeal to the Board (VA Form 10182) in August 2019, selecting Direct Review docket, a process under AMA in which the Board may only legally consider the evidence that was of record at the time of the June 2019 rating decision. 38 C.F.R. § 20.301. In a September 2020 decision, the Board denied service connection for bilateral carpal tunnel syndrome and increased ratings for PTSD and lumbar spine disabilities. The Veteran appealed that decision to the Court of Appeals for Veterans Claims (Court), which vacated the decision pursuant to a June 2021 Joint Motion for Remand. 1. Entitlement to service connection for carpal tunnel syndrome of the right upper extremity is remanded. 2. Entitlement to service connection for carpal tunnel syndrome of the left upper extremity is remanded. The June 2019 VA examiner failed to account for the Veteran's lay statements that he had stiffness in both hands and tingling when he separated from active service. Additionally, the examiner stated the Veteran's carpal tunnel was due to working with computers but failed to provide a rationale as to whether the Veteran's 15 years of active duty service working as an information systems operator was related to the development of the condition. Based on the above, pursuant to the Court's June 2021 order, the Board finds a remand is requried in order to correct a predecisional duty to assist error. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based on an inaccurate factual premise has no probative value); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). 3. Entitlement to a rating in excess of 20 percent for a lumbar spine disability is remanded. The May 2019 VA examiner checked the box indicating the Veteran's spine resulted in no radiculopathy. However, as noted by the Court, in a December 2018 private medical examination report, the examiner indicated the Veteran's lumbar spine condition does cause some radiculopathy. It was unclear to what extent based on the limited amount of information within the December 2018 private medical report. Accordingly, the Board finds the May 2019 VA examination is inadequate because it relies on inaccurate facts. See Reonal, 5 Vet. App. 458. Therefore, a remand is required to correct a pre-decisional duty to assist error. 4. Entitlement to an initial rating in excess of 30 percent for PTSD is remanded. In the January 2019 private medical examination and opinion, the Veteran reported recurrent thoughts of death, including suicidal ideation on occasion. However, the examiner indicated the Veteran did not suffer from suicidal ideations; thus, the examination is inadequate. Id. Additionally, in an April 2019 VA examination, the examiner also indicated no suicidal ideation, but it is clear from the Veteran's April 2019 statement that he did in fact experience suicidal ideation and thoughts of death. Id. Therefore, the Board finds both examinations are inadequate based on their reliance on inaccurate facts, and a remand is required to correct a pre-decisional duty to assist error. The matters are REMANDED for the following action: 1. The AOJ should arrange for a VA examination of the Veteran to determine the nature and likely cause of any bilateral carpal tunnel syndrome disability. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) The examiner should assume the Veteran has a diagnosis of bilateral carpal tunnel syndrome. (b.) For the Veteran's bilateral carpal tunnel syndrome, is it at least as likely as not (50% or greater probability) that such disability was either incurred in or otherwise related to the Veteran's military service? Please explain why. In answering the above, the examiner must address the Veteran's law statements that he had stiffness in both hands and tingling when he separated from active service and 15 years active-duty service working as an information systems operator. The examiner is reminded that the Veteran is competent to provide information about observable symptoms and events. The examiner should assume, for the purposes of the opinions, that the Veteran's reports are both accurate and credible. A detailed explanation (rationale) is required for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested.) 2. The AOJ should arrange for an examination of the Veteran to assess the current severity of his service-connected PTSD. The examiner must review the entire record (including this remand) in conjunction with the examination and note such review was conducted. The examiner should provide a full description of the disability and report all signs and symptoms associated with the Veteran's disability. (a.) The examiner must specifically address the Veteran's lay statements regarding his reports of suicidal thoughts and ideation. See November 2018 private medical examination and April 2019 statement. The examiner is reminded that the Veteran is competent to provide information about observable symptoms and events. The examiner should assume, for the purposes of the opinions, that the Veteran's reports are both accurate and credible. 3. The AOJ should arrange for an orthopedic examination of the Veteran to assess the current severity of his service-connected lumbar spine disability. The examiner must review the entire record in conjunction with the examination and note such review was conducted. Pathology, symptoms (frequency and severity), and any associated impairment of function should be described in detail. All indicated tests or studies should be completed. Specifically, the Veteran should also be scheduled for an examination for any radiculopathy reported in connection to his lumbar spine disability. Range of motion measurements should be included for active and passive motion in both weight-bearing and non-weight-bearing circumstances, including for the opposite undamaged joint, if applicable. If pain is noted, the point in the range of motion at which pain starts should be clearly noted. (Continued on the next page) If feasible, the examiner must assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss, using lay observations specifically elicited from the Veteran. If not feasible, the examiner must provide a detailed explanation and rationale for why such could not be accomplished. Specifically, if the medical professional cannot provide an opinion without resorting to mere speculation, he or she must provide a complete explanation for why an opinion cannot be rendered; a rationale based on the fact that the Veteran is not having a flare-up at the time of the examination will not be deemed adequate. David Gratz Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Williams, 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.