Citation Nr: 21072931 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 17-04 496 DATE: December 6, 2021 REMANDED Entitlement to a compensable rating for a right ankle sprain is remanded. Entitlement to a rating in excess of 10 percent for an anxiety disorder is remanded. Entitlement to service connection for a corneal disorder is remanded. Entitlement to service connection for an eye disorder claimed as dry eye syndrome is remanded. Entitlement to service connection for plantar fasciitis of the right foot is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1989 to February 1995 and from April 2001 to November 2013. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2014 rating decision by the Department of Veterans Affairs (VA). 1. Entitlement to a compensable rating for a right ankle sprain is remanded. 2. Entitlement to a rating in excess of 10 percent for an anxiety disorder is remanded. A review of the record indicates that the Veteran last received an examination for these disabilities in October 2013. Moreover, the Board notes that the Veteran's claims file does not contain any private treatment records or VA treatment records. Therefore, the Board finds that the current medical evidence is inadequate to properly evaluate the severity of the Veteran's disabilities. Accordingly, VA's duty to assist includes providing a new medical examination when the available evidence is too old for an adequate evaluation of the current condition and the disability may have worsened. Thus, for the above stated reasons, the Board finds a remand is necessary to afford the Veteran contemporaneous examinations to determine the current severity of his disabilities. See Allday v. Brown, 7 Vet. App. 517, 526 (1995) (indicating that, where the record does not adequately reveal the current state of the claimant's disability, fulfillment of the statutory duty to assist requires a contemporaneous medical examination, particularly if there is no additional medical evidence that adequately addresses the level of impairment of the disability since the previous examination). 3. Entitlement to service connection for a corneal disorder is remanded. 4. Entitlement to service connection for an eye disorder claimed as dry eye syndrome is remanded. In October 2013, the Veteran attended a VA eye examination. Following the examination, the examiner opined that the Veteran did not currently meet the diagnostic criteria for an eye disorder. The examiner simply stated that there is no diagnosis because there is no pathology to render a diagnosis. The Board finds this opinion to be inadequate because it is not based on an accurate set of facts. Specifically, the Board notes that the VA examination report indicated that the examiner did not review any of the Veteran's medical information, but the examiner still marked that the Veteran was never diagnosed with an eye condition when in fact he was diagnosed with a contact lens induced corneal disorder while on active duty. Moreover, the Board further finds this opinion inadequate because the examiner did not provide a thorough and well-reasoned analysis that addressed the Veteran's contention that his current symptoms manifested while on active duty. Thus, for the above stated reasons, a remand is required to obtain a more complete medical opinion as to the nature and etiology of the Veteran's claimed eye disorders. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.310; Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate); Bloom v. West, 13 Vet. App. 185, 187 (1999) (a medical opinion without supporting clinical data or other rationale does not provide the required degree of medical certainty). Entitlement to service connection for plantar fasciitis of the right foot is remanded. The Board notes that the Veteran attended a VA examination for this issue in October 2013. Following the examination, the examiner opined that the Veteran did not currently meet the diagnostic criteria for right foot disorder. The examiner simply stated that there is no diagnosis because there is no pathology to render a diagnosis. The Board finds this opinion to be inadequate because it is not based on an accurate set of facts. Specifically, the Board notes that the VA examination report indicated that the examiner did not review any of the Veteran's medical information, but the examiner still marked that the Veteran was never diagnosed with a foot condition when in fact he was diagnosed and treated for plantar fasciitis while on active duty. Moreover, the Board further finds this opinion inadequate because the examiner did not provide a thorough and well-reasoned analysis that addressed the Veteran's contention that his current symptoms manifested while on active duty. Thus, for the above stated reasons, a remand is required to obtain a more complete medical opinion as to the nature and etiology of the Veteran's condition. See Barr; supra. The matters are REMANDED for the following actions: 1. Contact the Veteran and ask the Veteran if the Veteran is receiving treatment from a private medical provider. If the Veteran is receiving treatment from a private medical provider, the RO should take all necessary steps to acquire these records. 2. Obtain any VA treatment records from October 10, 2013 to the present. 3. Schedule the Veteran for additional VA examinations in order to determine the severity of his right ankle sprain and his anxiety disorder. The examiner must fully describe the functional impairment stemming from the severity, frequency, and duration of the symptoms attributable to each disability, to include the impact of the Veteran's employability. 4. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran's claimed eye disabilities. The electronic claims file must be reviewed by the examiner. All indicated testing and studies must be conducted, and all pertinent symptomatology must be reported in detail. (A). Identify all eye disorders that are currently present. (B). Is it at least as likely as not (50 percent probability or greater) that the Veteran's eye disorder, had its onset in service or is caused by or related at least in part to his active service? The examiner must address the in-service diagnosis of a contact lens induced corneal disorder. 5. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran's right foot disability. The electronic claims file must be reviewed by the examiner. All indicated testing and studies must be conducted, and all pertinent symptomatology must be reported in detail. (A). Identify all right foot disorders that are currently present. (B). Is it at least as likely as not (50 percent probability or greater) that the Veteran's right disorder, had its onset in service or is caused by or related at least in part to his active service? The examiner must address the in-service diagnosis of right foot plantar fasciitis. The examiner's opinion must include a complete rationale for all opinions expressed. In providing all of the requested opinions, the examiner should consider the Veteran's competent lay claims regarding the observable symptoms he has experienced. SCOTT W. DALE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Rescan, 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.