Citation Nr: 21005365 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 17-12 885 DATE: February 1, 2021 REMANDED Entitlement to service connection for a heart disability to include, ischemic heart disease (IHD) is remanded. Entitlement to service connection for shrapnel scars on the back and under the arms is remanded. Entitlement to service connection for bilateral upper extremity diabetic neuropathy is remanded. Entitlement to service connection for bilateral lower extremity diabetic neuropathy is remanded. REASONS FOR REMAND The Veteran had active service in the United States Army from September 1969 to April 1972. He was awarded the Vietnam Service Medal and Vietnam Campaign Medal with 60 device, among other decorations, for this service. These matters come before the Board of Veterans' Appeals (Board) from a June 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office. In February 2020, the Veteran testified before the undersigned Veterans Law Judge. A November 2020 letter informed the Veteran that due to an audio malfunction during the hearing that a copy of the transcript would not be associated with his claims file. The Veteran was offered an additional hearing and declined. In light of the hearing not being associated with the claims file, the Board has sympathetically considered all correspondence from the Veteran throughout the appeal period. 1. The Claims on Appeal are Remanded. The Veteran contends service connection is warranted for a heart disability, shrapnel scarring on the back and arms, and bilateral upper and lower extremity neuropathy. After review of the evidence, a remand is necessary to allow the Board to make a fully informed decision. In November 2013, the Veteran filed in pertinent part, claims for service connection for a heart disability, as due to herbicide exposure, bilateral neuropathy, and shrapnel scars on his back and underarms. In April 2014, the Veteran underwent a VA examination to determine the etiology of any peripheral neuropathy. The VA examiner indicated that there was not enough evidence to support a diagnosis of diabetic peripheral neuropathy due to a lack of objective findings. However, upon examination, the Veteran was found to have symptoms attributable to diabetic peripheral neuropathy, including moderate intermittent pain and mild paresthesias and numbness. An addendum opinion was obtained and the VA physician indicated that a recent EMG confirmed a diagnosis of right carpal tunnel syndrome and no electrical evidence of a diffuse large fiber peripheral polyneuropathy of the upper extremities. VA treatment records associated with the claims file appear to indicate a diagnosis of, and treatment for neuropathy. Further, the Veteran has indicated he is prescribed medications for diabetic neuropathy. VA must afford a veteran a medical examination and/or obtain a medical opinion when it is necessary to make a decision on his or her claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). To that end, when VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). After review of the record, a remand is necessary to determine whether the Veteran has a current diagnosis of bilateral upper and lower extremity diabetic neuropathy. Regarding the claim for service connection for shrapnel scars, the Veteran submitted 1971 letters that he sent home from Vietnam indicating he sustained injuries to his back that required bandaging. The Veteran has also submitted a 1975 Congressional inquiry where he reported treatment for shrapnel wounds after an attack. To date, the Veteran has not been provided an examination to determine the nature and etiology of any shrapnel scars, as such, a remand is necessary. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A(d)(2), 38 C.F.R. § 3.159(c)(4)(i). Finally, the Veteran is presumed to have exposure to herbicides, including Agent Orange, based on his service in the Republic of Vietnam. VA and private treatment records show treatment for various heart disabilities, but it is unclear whether the Veteran has ischemic heart disease. The Veteran has not been provided an examination to determine the nature and etiology of any heart disabilities, as such, a remand is necessary. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A(d)(2), 38 C.F.R. § 3.159(c)(4)(i). The matters are REMANDED for the following action: 1. Associate all VA treatment records since February 2017 with the electronic claims file. 2. Schedule the Veteran for a VA heart examination to determine the nature and etiology of any currently diagnosed heart disabilities. The claims file must be provided to and reviewed by the examiner in conjunction with the examination. All indicated tests and studies should be performed, and all findings should be clearly set forth in detail. After review of the claims file and examination of the Veteran, the examiner should provide a diagnosis of all heart disabilities present during the appeal period, to include whether the Veteran has ischemic heart disease. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's heart disease arose in service or is etiologically related to his military service, to include his presumed exposure to herbicides. A clear rationale for all opinions with a discussion of the facts and medical principles involved should be provided. If the examiner is unable to offer the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2011). 3. Schedule the Veteran for a VA scar examination to determine whether the Veteran has any residual shrapnel scarring on his back and arms due to his described in-service injuries. The examiner should provide the measurements of any scar(s) identified and associated with the alleged in-service injury and indicate whether they are unstable or painful. After reviewing the claims file and performing any necessary tests, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's residual scar of the back and arms were caused by or otherwise related to service. 4. Schedule the Veteran for a VA examination to determine the etiology of the Veteran's current bilateral upper or lower extremity neuropathy. The examiner must have the appropriate expertise and be provided access to the electronic claims file. The examiner must indicate review of the claims file in the examination report. The examiner is asked to provide the following opinions: a) Is it at least as likely as not (50 percent probability or greater) that any current upper extremity or lower neuropathy was incurred in or caused by the Veteran's active military service? b) Is it at least as likely as not (50 percent probability or greater) that any current bilateral upper or lower extremity neuropathy is caused by the Veteran's service-connected disabilities, to include diabetes mellitus? c) If not caused by the service-connected disabilities, is it at least as likely as not (50 percent probability or greater) that any bilateral upper or lower extremity neuropathy is aggravated (worsened in severity beyond the natural progression of the disease) by the Veteran's service-connected disabilities, including diabetes mellitus? (Continued on the next page)   If the VA examiner opines that any bilateral upper or lower extremity neuropathy is aggravated by the service-connected disabilities, he/she should indicate the degree of disability before aggravation and the current degree of disability. A rationale should be given for all opinions and conclusions rendered. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Teague, 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.