Citation Nr: 21074744 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 16-52 715 DATE: December 16, 2021 REMANDED Entitlement to service connection for carpal tunnel syndrome (CTS) of the right upper extremity is remanded. REASONS FOR REMAND The Veteran had active duty service from February 1986 to February 1989 and from February 1993 to August 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In June 2021, the Board remanded the above issue for a VA examination for the Veteran's claim of entitlement to service connection for right hand CTS. There has not been substantial compliance with the Board remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (Board remand confers a right on a claimant to compliance with the remand order). Following the June 2021 remand, the Veteran underwent a VA peripheral nerves conditions in July 2021. The examiner opined that it was less likely than not that the Veteran's current CTS was incurred in or caused by the claimed in-service injury, event, or illness. The examiner's reasoning consists solely of listing the Veteran's service dates and that available records are silent for the condition until approximately 2014. The examiner also opined that it was less likely than not that the Veteran's CTS is proximately due to, or the result of, a service connected condition. The rationale provided for this opinion is identical to that provided for the direct service connection opinion, again consisting only of service dates and the first available instance of CTS treatment in the Veteran's record. The Board finds the July 2021 examination reports to be inadequate. The examiner appears to rely solely on the absence of clinical treatment for a large period of time directly after service as the basis for the negative nexus opinions. However, the absence of documented treatment cannot be the sole basis for finding an uncorroborated statement not credible. Barr v. Nicholson, 21 Vet. App. 303 (2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) ("if the Board concludes that lay evidence presented by a Veteran is credible and ultimately competent, the lack of contemporaneous medical evidence should not be an absolute bar to the Veteran's ability to prove his claim of entitlement to disability benefits based on that competent lay evidence"). Moreover, the June 2021 remand explicitly directed the examiner to address the Veteran's contentions, which the July 2021 examiner failed to do. Additionally, remand directives also instructed the Veteran to address the issue of aggravation, however an opinion as to aggravation was not provided. Once the Secretary undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, he must provide an adequate one. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, additional development to obtain an adequate medical nexus opinion in this matter is necessary. The matter is REMANDED for the following action: 1. Contact the Veteran and ask him to identify any outstanding VA or private medical records reflecting treatment for his claimed neuropathies and hypertension. If such records are identified, then obtain those records and associate them with the electronic claims file. To expedite this action, the Veteran is encouraged to submit any additional new VA or new private medical records himself. 2. Schedule the Veteran for a VA examination with the appropriate clinician to determine the nature and etiology of the Veteran's right upper extremity carpal tunnel syndrome. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records and lay statements. The examiner should note that the Veteran is competent to attest to factual matters of which he had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. 3. 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.) Whether it is at least as likely as not that the Veteran's right upper extremity carpal tunnel syndrome is at least as likely as not (50 percent or greater probability) causally related to active service. (b.) whether it is at least as likely as not that the Veteran right upper extremity carpal tunnel syndrome was either caused by or aggravated by a service-connected disability, to include his back disability. The opinion must address whether the disability increased in severity beyond its natural progression (i.e., was aggravated). If aggravation is found, please identify to the extent possible the baseline level of disability prior to the aggravation. 4. Thereafter, readjudicate the claim on appeal. If any benefit sought on appeal is not granted in full, the Appellant should be furnished with a Supplemental Statement of the Case and afforded an opportunity to respond before the file is returned to the Board for further appellate consideration. John J. Crowley Veterans Law Judge Board of Veterans' Appeals Attorney for the Board V. Woehlke 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.