Citation Nr: 21073982 Decision Date: 12/13/21 Archive Date: 12/13/21 DOCKET NO. 16-33 374 DATE: December 13, 2021 ORDER Entitlement to service connection for a post operative left anterior cubital fossa scar is granted. REMANDED Entitlement to service connection for a left upper extremity neurological disability, to include left radial nerve palsy, is remanded. FINDING OF FACT A post-operative left anterior cubital fossa scar originated during active service. CONCLUSION OF LAW The criteria for service connection for a post-operative left anterior cubital fossa scar have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from January 1969 to June 1969 and from March 1985 to January 2002. Service Connection for a Left Elbow Area Scar Service connection may be granted for chronic disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. The service treatment records reflect that the Veteran underwent left upper extremity surgery. An October 2001 treatment record states that the Veteran underwent left radial head exploratory surgery. The report of a February 2020 Department of Veterans Affairs (VA) elbow examination states that the Veteran exhibited a post-operative left anterior cubital fossa scar measuring 8 centimeters by .05 centimeters. The service treatment records document that the Veteran underwent left radial head exploratory surgery. On VA examination, the Veteran exhibited a post-operative left anterior cubital fossa scar. Therefore, service connection for a post-operative left anterior cubital fossa scar is warranted. REASONS FOR REMAND Entitlement to service connection for a left upper extremity neurological disability, to include left radial nerve palsy, is remanded. The report of a February 2020 VA peripheral nerve examination states that: "the Veteran was diagnosed with a left radial nerve injury after his surgery in 2001;" "he had no further symptoms relating to this injury until 4-5 years ago when he noted weakness and sensory symptoms;" "he was not seen by any neuromuscular specialists for this and has not has an appropriate work-up for this;" "thus, until the patient has a complete work-up for this condition, I am unable to render a definitive diagnosis;" "I would also recommend that the patient undergo an electromyographic study;" and "after a complete work-up has been performed by a neurologist trained in neuromuscular medicine, he should be reassessed for C&P." When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). VA's failure to conduct further evaluations and studies as recommended by VA's own examiner constitutes a breach of its statutory duty to assist the Veteran. Hyder v. Derwinski, 1 Vet. App. 221 (1991). The Board finds that VA neurological evaluation is needed Clinical documentation dated after July 2020 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claim. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated any left upper extremity neurological disability. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain any VA treatment records not of record, to include those pertaining to treatment after July 2020. 3. Schedule the Veteran for a VA neurological examination conducted by a medical doctor to assist in determining the nature and etiology of any identified left upper extremity neurological disabilities. The examiner must review the record, including the February 2020 examination report, and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all left upper extremity neurological disabilities identified. (b) Opine whether it is at least as likely as not (a 50 percent probability or greater) that any identified left upper extremity neurological disability had its onset during active service or is related to any incident of service, including the documented October 2001 left radial head exploratory surgery and left radial nerve palsy. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.R. Kardian, 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.