Citation Nr: 21071992 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 14-21 516 DATE: December 2, 2021 REMANDED Entitlement to service connection for cyst of mouth is remanded. Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for right lateral epicondylitis (also claimed as elbow and forearm with pain and tendonitis) is remanded. Entitlement to service connection for right wrist sprain (also claimed as wrist with pain and tendonitis) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1979 to July 2001. This case comes to the Board of Veterans' Appeals (Board) from a December 2012 rating decision that denied service connection for cyst of mouth and a left ankle disability. In August 2017, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In May 2018, the Board remanded the claims of service connection for cyst of mouth and a left ankle disability for further development. A November 2018 rating decision denied service connection for right lateral epicondylitis and right wrist sprain. In January 2021, the Board remanded all claims of service connection for further development. The Board notes that VA treatment records were added to the Veteran's claims file after the September 2021 Supplemental Statement of the Case. While the Veteran has not waived initial agency of original jurisdiction (AOJ) review of this evidence, there is no prejudice to the Veteran because the AOJ can consider these records on remand. Entitlement to service connection for cyst of mouth is remanded. The January 2021 remand instructed the AOJ to provide the Veteran with a VA Form 21-4142 for relevant dental treatment from private providers, to include Dr. G.P. and Northwest Oral and Maxillofacial Surgery Associates. Following remand, the Veteran stated on several occasions that records cannot be obtained from Dr. G.P. because he retired. Accordingly, it appears that additional attempts to obtain records from Dr. P. would be futile. However, an undated form, received by the AOJ in June 2014, indicates that the Veteran was referred to Northwest Oral and Maxillofacial Surgery Associates for a cyst where #17 wisdom tooth was extracted during service. Because a new VA examination is necessary, the Veteran should be provided another opportunity to complete a VA Form 21-4142 for relevant dental treatment from this provider. Remand is also required to provide the Veteran with a new VA examination. The May 2019 VA examiner diagnosed the Veteran with inflammatory conditions of the jaws. However, it is not clear if this is the diagnosis for cyst of mouth or a separate diagnosis. If this is a separate diagnosis, the examiner did not appear to consider the undated form received by the AOJ in June 2014. See McClain v. Nicholson, 21 Vet. App. 319, 32 (2007) (stating that an examiner must consider a disability during the pendency of the appeal even if the disability resolves prior to the Board's adjudication of the claim). If cyst of mouth is diagnosed, the examiner must opine whether this disability is at least as likely as not related to dental work during service, to include root canals or wisdom teeth extractions. Entitlement to service connection for a left ankle disability is remanded. Remand is required because the July 2021 VA examiner's opinions are inadequate. The VA examiner did not explain whether the Veteran's left ankle edema resulted in functional impact. While the VA examiner stated that a diagnosis of arthritis was not warranted and x-rays were not clinically indicated, the examiner did not reconcile that conclusion with evidence identified in the January 2021 remand. While the VA examiner provided a negative nexus opinion, the examiner did not consider the evidence identified in the January 2021 remand, and relied on the absence of evidence after service without providing a proper foundation. Entitlement to service connection for right lateral epicondylitis is remanded. Remand is required because the July 2021 VA examiner's opinion is inadequate. While the VA examiner provided a negative nexus opinion, the examiner did not consider the evidence identified in the January 2021 remand, and relied on the absence of evidence after service without providing a proper foundation. Entitlement to service connection for right wrist sprain is remanded. Remand is required because the July 2021 VA examiner's opinion is inadequate. While the VA examiner provided a negative nexus opinion, the examiner did not consider the evidence identified in the January 2021 remand, and relied on the absence of evidence after service without providing a proper foundation. The examiner also incorrectly stated that there were no complaints of a right wrist condition during service. The matters are REMANDED for the following actions: 1. Obtain the Veteran's VA treatment records for the period from November 2021 to the present. 2. Ask the Veteran to complete a VA Form 21-4142 for private dental treatment from Northwest Oral and Maxillofacial Surgery Associates. Make two requests for the authorized records from the provider, unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for a VA examination for cyst of mouth. The examiner must review the claims file and provide a rationale for all opinions. The examiner must opine whether the Veteran had a diagnosis of cyst of mouth at any point during or proximate to the claim filed in September 2011, even if it resolved during the period of the appeal. If cyst of mouth is not diagnosed, the examiner must reconcile that conclusion with an undated form, received by the AOJ in June 2014, indicating that the Veteran had a cyst where #17 wisdom tooth was extracted during service. If cyst of mouth is diagnosed, the examiner must opine whether this disability is at least as likely as not related to dental work during service, to include root canals or wisdom teeth extractions. 4. Schedule the Veteran for a VA examination for a left ankle disability. The examiner must review the claims file and provide a rationale to support the opinions. The VA examiner should perform all necessary testing. The examiner must identify the nature of the Veteran's left ankle disability, to include arthritis and left ankle edema. If arthritis is not diagnosed and additional testing is not deemed warranted, the examiner must reconcile that opinion with an August 2012 record noting bilateral ankle x-rays showing mild arthrosis, a November 2018 record indicating possible left ankle arthritic changes and bone spurs, and a July 2020 x-ray suggesting that a complete left ankle radiograph may be necessary. If left ankle edema is not diagnosed, the examiner must reconcile that opinion with an August 2018 record diagnosing left ankle edema. For each left ankle disability, the examiner must opine whether it is at least as likely as not related to service, to include a January 1996 injury during service. The examiner should consider an August 2001 record showing left ankle pain during range of motion testing, an April 2011 record and an August 2018 record indicating left ankle edema, and the Veteran's lay statements. If left ankle edema is diagnosed, the examiner must opine whether this disability is at least as likely as not proximately due to the Veteran's service-connected left knee disability. The examiner should consider an August 2018 record indicating that left ankle edema was likely related to wearing a left knee brace. Similarly, if left ankle edema is diagnosed, the examiner must opine whether this disability is at least as likely as not aggravated, i.e., worsened beyond its natural progression, by the Veteran's service-connected left knee disability. The examiner should consider an August 2018 record indicating that left ankle edema was likely related to wearing a left knee brace. If arthritis is diagnosed, the examiner must opine whether this disability at least as likely as not (1) manifested within one year after discharge from service or (2) was noted during service with continuity of the same symptomatology since service. The examiner is advised that a negative opinion may not be based solely on the absence of treatment during or after service and that the examiner must provide a proper foundation explaining why the absence of evidence is relevant in determining if the disability is related to service. 5. Schedule the Veteran for a VA examination for right lateral epicondylitis. The examiner must review the claims file and provide a rationale to support the opinions. The examiner must opine whether this disability is at least as likely as not related to service, to include an injury when a piece of heavy machinery was dropped on the right arm. The examiner should consider a March 1986 service record showing a chain fall accident, an August 2001 record noting a right forearm condition for the past six years, and the Veteran's lay statements. The examiner is advised that a negative opinion may not be based solely on the absence of treatment during or after service and that the examiner must provide a proper foundation explaining why the absence of evidence is relevant in determining if either disability is related to service. 6. Schedule the Veteran for a VA examination for right wrist sprain. The examiner must review the claims file and provide a rationale to support the opinions. The examiner must opine whether this disability is at least as likely as not related to service, to include an injury when the right wrist was lacerated and an injury when a piece of heavy machinery was dropped on the right arm. The examiner should consider November 1985 service records showing a laceration to the right wrist, a March 1986 service record showing a right wrist complaint due to a chain fall accident, an August 2001 record noting a right forearm condition for the past six years, and the Veteran's lay statements. The examiner is advised that a negative nexus opinion may not be based solely on the absence of treatment during or after service and that the examiner must provide a proper foundation explaining why the absence of evidence is relevant in determining if either disability is related to service. K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Ormson, 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.