Citation Nr: 21077286 Decision Date: 12/29/21 Archive Date: 12/29/21 DOCKET NO. 17-52 615 DATE: December 29, 2021 REMANDED Entitlement to service connection for carpal tunnel syndrome (CTS) of the right upper extremity (claimed as peripheral neuropathy) to include as due to diabetes mellitus is remanded. Entitlement to service connection for carpal tunnel syndrome (CTS) of the left upper extremity (claimed as peripheral neuropathy) to include as due to diabetes mellitus is remanded. Entitlement to a total disability evaluation based on individual unemployability (TDIU) for the period prior to May 3, 2016 is remanded. REASONS FOR REMAND The Veteran served in active-duty service with the Marine Corps from December 1967 to December 1969. This matter is on appeal from an October 2014 and April 2015 rating decision. The Veteran was afforded a September 2020 hearing before the undersigned Judge; a transcript of the hearing has been associated with the claims record. The Board remanded this appeal in April 2021 for additional development. Unfortunately, the Board finds that remand is warranted for additional development. In May 2014, the Veteran claimed bilateral upper neuropathy as due to his diabetes. Review of the record shows the Veteran reporting symptoms of numbness in his hands as well as issues where he "felt his carpal tunnel syndrome is coming back"; the examiner did not formally diagnosis carpal tunnel syndrome but listed the condition as an active problem. In an August 2014 VA examination for diabetes, the Veteran reported symptoms of cramping in his hands after using tools as well as dropping things. The examiner noted the Veteran reported a prior history of right-side carpal tunnel syndrome that required surgery in 2008 as well as a separate left-hand injury that also required surgery and "was told they also worked on [carpal tunnel syndrome] at some point." The examiner indicated that there was "old residuals [of carpal tunnel syndrome]" but did not offer an opinion to confirm the diagnosis or on the nature and etiology of the appealed issues. In a May 2016 VA examination for diabetes, the Veteran was noted to deny symptoms of numbness and tingling in his hands; the examiner indicated there was diabetic peripheral neuropathy but also noted that the Veteran's reported symptoms in August 2014 were due to his work history as a truck driver and not his diabetes. At the September 2020 hearing, the Veteran testified that he was unable to recall when he was diagnosed for carpal tunnel syndrome but described that he has had symptoms that were ongoing for a long time. The Board finds that further VA examination is warranted to specifically address whether the Veteran has carpal tunnel syndrome, and if so, the etiology of his claimed disability. The Board also notes that a March 2015 SSA inquiry indicates the Veteran has been receiving disability since July 2010. Review of the record does not show that the SSA decision or related SSA documents have been associated with the record. As the SSA records may provide pertinent evidence as to the Veteran's claims, remand is warranted to obtain these records that relate to the Veteran's claimed issues. See Golz v. Shinseki, 590 F.3d 1317, 1321 (2010). As such, the Board finds remand warranted to obtain an examination and to associate outstanding records with the claims record. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all updated and outstanding treatment records. 2. Confirm with the Social Security Administration (SSA) whether the Veteran is receiving SSA disability benefits, obtain his SSA records relating to his claims for bilateral carpal tunnel syndrome of the upper extremities and associate them with the Veteran's claims file. All records/responses received must be associated with the electronic claims file. 3. Schedule the Veteran for a VA examination to evaluate the nature and etiology of the Veteran's claimed right and left carpal tunnel syndrome. The examiner should note a review of the claims folder has been performed in conjunction with the report. After reviewing the file, the examiner should provide opinions on the following: (a.) Identify each current carpal tunnel syndrome. If the disability existed during the appeal period but has resolved, this should be made clear. (b.) For each right and left carpal tunnel syndrome identified, whether resolved or active, is it as least as likely as not (a 50 percent or greater probability) the Veteran's right and left carpal tunnel syndrome disability arose in service or is etiologically related to his military service? If the Veteran is diagnosed with only pain, the examiner must determine whether such results in any functional impairment. (c.) Is it as least as likely as not (a 50 percent or greater probability) the Veteran's right and left carpal tunnel syndrome was caused by or related to the Veteran's service-connected diabetes? (d.) Is it at least as likely as not (50 percent probability or more) that the Veteran's thoracolumbar spine disability is aggravated by the Veteran's service-connected diabetes? "Aggravation" is defined as any worsening beyond the natural progression of the disability. The examiner should establish a baseline level of disability prior to aggravation. If a baseline cannot be established, the examiner should explain why. (e.) In rendering the requested opinions, the VA examiner should identify and address any relevant medical and lay evidence to include the findings made in the August 2014 VA and May 2016 VA examinations for diabetes and diabetic peripheral neuropathy and the September 2020 hearing testimony. (f.) The examiner is advised that the Veteran is competent to report in-service events and treatment, and the Veteran's symptoms and history, and such reports and assertions must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports, the examiner must provide a reason for doing so. (g.) If the VA examiner is unable to provide an opinion without resort to speculation, he or she should explain whether the inability is due to the limits of the examiner's medical knowledge, medical knowledge in general or there is evidence that, if obtained, would permit the opinion to be provided. A clearly stated rationale for any opinion offered should be provided. 4. After completion of the above and any additional development deemed necessary, the issues on appeal should be reviewed with consideration of all applicable laws and regulations. If any benefit sought remains denied, the Veteran should be furnished a supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Yang, Attorney-Advisor 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.