Citation Nr: 21073072 Decision Date: 12/07/21 Archive Date: 12/07/21 DOCKET NO. 19-17 372 DATE: December 7, 2021 REMANDED Entitlement to service connection for peripheral neuropathy of the left upper extremity is remanded. Entitlement to service connection for peripheral neuropathy of the right upper extremity is remanded. Entitlement to service connection for peripheral neuropathy of the left lower extremity is remanded. Entitlement to service connection for peripheral neuropathy of the right lower extremity is remanded. Entitlement to service connection for aortic aneurysm, to include as secondary to service-connected coronary artery disease, is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1957 to October 1960 and from May 1962 to January 1971. The Veteran passed away in July 2019, and the appellant is his surviving spouse. This matter is on appeal from an October 2016 decision of a Department of Veterans Affairs (VA) Regional Office (RO). In April 2021, a videoconference hearing was held before the undersigned. A transcript of the hearing is in the record. The Board remanded the appeal in June 2021 for adequate opinions to be obtained. Unfortunately, there has not been substantial compliance with the remand directives, and remand is necessary again in order to properly develop the claim. Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for peripheral neuropathy of the left upper extremity is remanded. 2. Entitlement to service connection for peripheral neuropathy of the right upper extremity is remanded. 3. Entitlement to service connection for peripheral neuropathy of the left lower extremity is remanded. 4. Entitlement to service connection for peripheral neuropathy of the right lower extremity is remanded. The appellant contends that the Veteran's peripheral neuropathy was related to service or service-connected disability. Prior to his death the Veteran claimed service connection as secondary to coronary artery disease. See September 2016 VA Form 21-526EZ. Further, during the April 2021 hearing, the appellant reported that she believes the Veteran had early-onset peripheral neuropathy shortly after separation from service because he immediately experienced symptoms such as foot pain, an inability to sleep with sheets on his feet, difficulty balancing, and tingling in the feet after discharge that worsened through the years. VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim. 38 U.S.C. § 5103A(a)(1). Upon review of the record, the Board finds that opinions must be obtained to clarify the nature and etiology of the Veteran's disability because the opinions obtained since the last remand are not adequate for adjudication purposes. The Board directed VA in the June 2021 remand to obtain an opinion which adequately addresses the likelihood that the Veteran had early-onset peripheral neuropathy and was therefore entitled to presumptive service connection. Further, the record reflects that the Veteran was service connected for coronary artery disease. In April 2021, VA received an article from the National Institutes of Health (NIH) which states that vascular and blood problems can lead to neuropathy. Service connection may be established on a secondary basis for a disability caused or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a); see Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). If service connection could not be established on a presumptive basis, the Board directed the VA examiner to provide an opinion as to whether the Veteran's peripheral neuropathy was proximately due to or aggravated by his service-connected coronary artery disease (CAD). VA obtained opinions in July 2021 and August 2021 that contain conflicting rationale and do not contain rationale addressing whether CAD caused or aggravated the claimed peripheral neuropathy disability. See July 2021 Opinion; see also August 2021 Opinion. The examiner found that the Veteran manifests radiculopathy of the lower extremities that is due to lumbar spine disability, but the examiner did not address findings from December 2018 VA medical records showing idiopathic peripheral neuropathy and hereditary sensory neuropathy. See December 2018 Medical Record. Further, the examiner did not address the evidence listed above regarding a relationship between that vascular and blood problems can lead to neuropathy. The Board also notes that due to sentence structure and grammar, the opinions from the July 2021 and August 2021 reports are not clear as to their findings. The Veteran's representative contends the July and August 2021 opinions are inadequate, in part but not limited to, the examiner noting but disregarding the appellant's testimony about symptoms of shortly after discharge. See October 2021 Appellate Brief. An opinion is considered adequate when it is based on consideration of the Veteran's prior medical history and examinations and describes the disability in sufficient detail so that the Board's evaluation of the claimed disability is a fully informed one. Stefl v. Nicholson,21 Vet. App. 120, 124 2007). Given the lack of clear rationale and findings and the failure to address whether CAD caused or aggravated the claimed peripheral neuropathy disability, the July 2021 and August 2021 opinions are inadequate for adjudication purposes. O 5. Entitlement to service connection for aortic aneurysm, to include as secondary to service-connected coronary artery disease, is remanded. The appellant contends that the Veteran's aneurysm was proximately due to his service-connected coronary artery disease. The Veteran asserted in his September 2012 claim that he incurred aneurysms from heart surgery. See September 2012 VA Form 21-526b. Upon review of the record, the Board finds the most recent opinions are not adequate to address entitlement for direct and secondary service connection. In the most recent remand, the Board discussed prior examinations and directed VA to obtain adequate opinions on whether the Veteran's claimed aneurysm was caused or aggravated by CAD. VA obtained opinions in July 2021 that contain conflicting rationale and do not address whether CAD caused or aggravated the claimed aneurysm. See July 2021 Opinion. While the examiner noted risk factors for aneurysm, they did not address whether CAD, or treatment for CAD, could cause or aggravate aneurysm. The Veteran's representative also contends the July 2021 opinions are inadequate. See October 2021 Appellate Brief. Given the lack of clear rationale and findings, and the failure to address whether CAD caused or aggravated the claimed aneurysm disability, the July 2021 opinions are inadequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007). On remand, VA will request new opinions from a qualified examiner to address the appellant's contentions. The matters are REMANDED for the following action: Obtain an opinion from a different examiner. The reviewing clinician should be requested to provide an opinion (based on a review of the record) to answer the following: (a.) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran had early-onset peripheral neuropathy? The clinician is asked to address the lay testimony provided by the appellant, particularly the statements made during the hearing in which she described the symptoms she observed shortly after the Veteran returned from service. The examiner is also directed to review and discuss the Veterans' treatment from August 1990 where he reported lower extremity radicular symptoms and cervical myelomalacia. (b.) If not, is it at least as likely as not (a 50 percent or greater probability) that the Veteran's peripheral neuropathy, to include idiopathic peripheral neuropathy and hereditary sensory neuropathy was proximately due to or aggravated by his service-connected coronary artery disease? The examiner is directed to review and discuss the NIH article which states that vascular and blood problems can lead to neuropathy. If aggravation is found, specify the baseline of disability prior to aggravation, and, to the extent possible, the increase in disability resulting from the aggravation. (c.) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran's thoracic aortic aneurysm is related to an in-service injury, disease, or event, to include his presumed exposure to herbicide agents? (d.) If not, is it at least as likely as not (a 50 percent or greater probability) that the Veteran's aneurysm was proximately due to his service-connected coronary artery disease? (e.) If not, is it at least as likely as not (a 50 percent or greater probability) that the Veteran's aneurysm was aggravated (increased beyond the normal progression of the disease) by his service-connected coronary artery disease? If aggravation is found, specify the baseline of disability prior to aggravation, and, to the extent possible, the increase in disability resulting from the aggravation. In rendering an opinion, the clinician is asked to address the representative's contention that atherosclerosis can cause an aortic aneurysm. The examiner is also directed to address the Veteran's contention that he sustained aneurysm as a result of heart surgery. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical (Continued on the next page) community at large and not those of the particular examiner. J. B. FREEMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Trickey 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.