Citation Nr: 21075082 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 14-15 902A DATE: December 17, 2021 REMANDED Entitlement to service connection for a left shoulder disability is remanded. Entitlement to a separate compensable disability rating for service-connected painful facial scars is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from November 1983 to July 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to service connection for a left shoulder disability is remanded. In a December 2018 Board decision, the Board denied the Veteran's left shoulder claim in. The Veteran then appealed to the United States Court of Appeals for Veteran's Claims (CAVC), and in June 2020 CAVC vacated the December 2018 Board decision with regard to the left shoulder claim, granted a joint motion for partial remand (JMPR), and returned the case to the Board for action consistent with the JMPR. Specifically, the Parties to the June 2020 JMPR agreed that the Board relied on an inadequate January 2012 VA examination in which the examiner diagnosed the Veteran with left shoulder strain and noted results of a January 2012 x-ray with findings consistent with mild chronic rotator cuff injury but failed to address whether Veteran's documented mild chronic rotator cuff injury was related to service, and instead only opined as to the etiology of the left shoulder strain, despite the examination inquiry asking for an opinion on any current chronic left shoulder disability. The matter last appeared before the Board in December 2020, at which time the issue was remanded to the RO for further action consistent with the June 2020 JMPR. Accordingly, the Veteran underwent additional in person VA examination in February 2021 and June 2021. The February 2021 examiner failed to make any diagnoses of the condition due to the Veteran's disposition as noted by the examiner. Yet, the examiner still opined that the condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness or proximately due to a service-connected disability. The examiner provided no opinion as to whether the condition was aggravated by a service-connected condition. Then, the Veteran underwent the in-person June 2021 VA examination with a different examiner. This examiner diagnosed the Veteran with left shoulder strain, left acromioclavicular joint osteoarthritis, bilateral tendinitis, right degenerative arthritis, and right bursitis. However, this examiner's opinion as to the etiology is not of record. The Board finds that the examinations are inadequate. The February 2021 examination is first, inherently inadequate on its face as there is no opinion in regard to aggravation of the condition. Any medical opinion which addresses secondary service connection must include an aggravation opinion. See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310. Second, because the February 2021 VA examiner did not diagnose the Veteran with any condition, an opinion in regard to the etiology of the condition lacks the supporting data required for the Board to determine whether valid medical analysis was applied in formulating the opinion. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). A review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion. It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion. Id. at 304. The Board must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion. Id. These significant facts may or may not include matters evident from a review of the claims file, given the nature of the issue under consideration. Id. Finally, in this regard, as the February 2021 VA examiner failed to make any diagnosis, based on the June 2021 VA examination, as well as the entirety of the record, the Veteran has multiple left shoulder disabilities, but the February 2021 VA examiner only opined as to the left shoulder strain, which renders it inadequate. As such, remand is necessary to obtain adequate opinions in compliance with the June 2020 JMPR and prior Board remand. 2. Entitlement to a separate compensable disability rating for service-connected painful facial scars is remanded. In the December 2020 Board remand, the Board remanded this issue noting that the Veteran reported that her facial scars were painful and tender, but did not indicate which scars were painful and tender. Previous examinations reported non painful and stable scars. The Board notes that under 38 C.F.R. § 4.118, Schedule of Ratings for the skin, Diagnostic Code 7800 Note 4 warrants a separate evaluation for disabling effects other than disfigurement that are associated with individual scar(s) of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury, under the appropriate diagnostic code. As such, the Board directed that an examination be obtained to assess the severity level of the Veteran's scars. The Board specifically directed that the examiner addresses the Veteran's competent lay statements regarding the painful and tender facial scars. The Veteran underwent an examination in February 2021. The examiner noted that the Veteran was a poor historian on the day of examination and noted the Veteran's disposition. Although the examiner reported the chin scar was painful, the examiner also then noted that the Veteran reported no painful scars. Moreover, the record fails to indicate that the examiner addressed the Veteran's lay statements regarding her painful and tender facial scars as there is no dictated medical history beyond the onset, course and location of the five scars noted. The Board notes that under Diagnostic Code 7804 evaluation is based on the number of unstable or painful scars. Thus, although the examiner was unable to perform the examination due to the Veteran's noted disposition, the examiner failed to directly address the Veteran's lay statements of record. The Board finds the opinion to be inadequate as the Board is unable to determine whether the examination is an adequate assessment of the severity level of the disability. Id. Hence, remand is warranted to obtain an adequate examination in compliance with the prior Board remand. 3. Entitlement to a TDIU rating due to service-connected disabilities. Finally, the Board notes the issue of entitlement to a TDIU rating must be held in abeyance at this time, because this issue is intrinsically intertwined with the above-noted remanded issues. See Harris v. Derwinski, 1 Vet. App. 180(1991). The matters are REMANDED for the following action: 1. Forward the claims file to the examiner that performed the June 2021 VA examination. The examiner must note review of the claims file and provide an opinion as directed below regarding the nature and etiology of any currently diagnosed let shoulder disabilities. If upon review of the claims file the examiner determines that an in-person examination is necessary, schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) to determine the onset and etiology left shoulder conditions. Any indicated studies should be performed. Following a review of the relevant records and lay statements, the examiners should state whether any currently diagnosed left shoulder disabilities at least as likely as not originated during her period of active service or was otherwise etiologically related to her active service, to include as secondary to a service-connected disability. For purposes of these opinions, the examiner should explicitly demonstrate consideration of the Veteran's lay accounts relating to her left shoulder, to include symptoms experienced during active service and since. The examiner must provide a complete rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 2. Schedule a VA examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) to ascertain the current severity of her service-connected facial scar disabilities. All pertinent evidence of record should be made available to and reviewed by the examiner. Any indicated studies should be performed. Specifically, the examiner must explicitly demonstrate consideration of the Veteran's lay statements, both concurrent with the examination and those previously asserted during the claims period regarding her scars. (Continued on the next page) 3. Develop and adjudicate the issue of entitlement to a total disability rating due to service-connected disabilities. Zi-Heng Zhu Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Q. Alli, 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.