Citation Nr: 21008648 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 14-21 322 DATE: February 17, 2021 ORDER As the claim is withdrawn, the claim of entitlement to service connection for muscle spasms is dismissed. As the claim is withdrawn, the claim of entitlement to an evaluation in excess of 40 percent for degenerative disk disease of the lumbar spine, status post L2 through S1 fusion (lumbar spine disability), is dismissed. As the claim is withdrawn, the claim of entitlement to an initial compensable evaluation for bilateral hearing loss is dismissed. As the claim is withdrawn, the claim of entitlement to a temporary total rating based on convalescence due to left shoulder surgery is dismissed. The petition to reopen the previously denied claim for service connection for heart palpitations is granted. REMANDED Entitlement to service connection for a heart disability (claimed as heart palpitations and heart attack), to include as due to service-connected hypothyroidism, is remanded. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities, to include as due to service-connected degenerative disk disease of the lumbar spine, status post L2 through S1 fusion, is remanded. Entitlement to service connection for a left shoulder disability, to include as due to service-connected disabilities, is remanded. Entitlement to service connection for a left ankle disability, to include as due to service-connected disabilities, is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. On November 17, 2020, prior to the promulgation of a decision in the appeal, the Veteran notified the Board at his hearing on appeal that he sought to withdraw his claim of entitlement to service connection for muscle spasms.  2. On November 17, 2020, prior to the promulgation of a decision in the appeal, the Veteran notified the Board at his hearing on appeal that he sought to withdraw his claim of entitlement to a rating in excess of 40 percent for degenerative disk disease of the lumbar spine, status post L2 through S1 fusion. 3. On November 17, 2020, prior to the promulgation of a decision in the appeal, the Veteran notified the Board at his hearing on appeal that he sought to withdraw his claim of entitlement to an initial compensable rating for bilateral hearing loss. 4. On November 17, 2020, prior to the promulgation of a decision in the appeal, the Veteran notified the Board at his hearing on appeal that he sought to withdraw his claim of entitlement to a temporary total rating based on convalescence due to left shoulder surgery. 5. Evidence received since the July 1993 rating decision is neither cumulative nor redundant, and, when considered with previous evidence of record, raises a reasonable possibility of substantiating the claim of entitlement to service connection for heart palpitations. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the claim for entitlement to service connection for muscle spasms by the Veteran have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The criteria for withdrawal of the claim for entitlement to an evaluation in excess of 40 percent for degenerative disk disease of the lumbar spine, status post L2 through S1 fusion, by the Veteran have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 3. The criteria for withdrawal of the claim for entitlement to an initial compensable evaluation for bilateral hearing loss by the Veteran have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 4. The criteria for withdrawal of the claim for entitlement to a temporary total rating based on convalescence due to left shoulder surgery by the Veteran have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 5. The July 1993 rating decision denying the claim for service connection for heart palpitations is final; and new and material evidence has been received to reopen the claim. 38 U.S.C. §§ 5103, 5103A, 5108, 7105(c); 38 C.F.R. §§ 3.104, 3.156(a), (b), 20.1103. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1978 to January 1993. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In January 2018, the Veteran testified at a Board hearing before one of the undersigned Veterans Law Judges (VLJs). Then, in November 2020, the Veteran testified at a second hearing before another of the undersigned VLJs. During the November 2020 hearing, the Veteran was afforded an opportunity to testify at another hearing before a third VLJ. See Arneson v. Shinseki, 24 Vet. App. 379, 389 (2011). However, the Veteran waived his right to a third hearing. Nevertheless, pursuant to 38 U.S.C. § 7102(a), proceedings before the Board may only be assigned to one individual VLJ or to a panel of not less than three. Accordingly, a third VLJ was assigned by a Deputy Vice Chairman of the Board to participate in making a final determination in the instant appeal. The Board also notes that during the November 2020 hearing, the Veteran waived agency of original jurisdiction (AOJ) review of the additional evidence associated with the claims file following the issuance of the February 2019 SSOC. A transcript of each Board hearing has been associated with the claims file. In a March 2018 decision, the Board dismissed the issues of entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) and entitlement to an evaluation in excess of 10 percent for a lumbar laminectomy scar based on the Veteran’s withdrawal of those claims during the January 2018 Board hearing. The Board additionally remanded the claim of entitlement to a rating in excess of 40 percent for the Veteran’s lumbar spine disability and entitlement to a TDIU in order to obtain VA examinations and medical opinions. The Veteran was subsequently afforded VA back examinations in May 2018 and October 2018. In the March 2018 decision, the Board also remanded several issues in order for the AOJ to issue a statement of the case (SOC) addressing those claims. Manlincon v. West, 12 Vet. App. 238, 240-241 (1999). Those issues included: entitlement to service connection for muscle spasms, peripheral neuropathy of the bilateral lower extremities, left shoulder disability, left ankle disability, heart palpitations and heart attack; entitlement to an initial compensable rating for service-connected bilateral hearing loss; and entitlement to temporary total evaluations based on convalescence due to the Veteran’s service-connected lumbar spine surgery and nonservice-connected left shoulder surgery. Pursuant to the Board remand, SOCs were issued in June 2018 (peripheral neuropathy of the bilateral lower extremities), September 2018 (left ankle, left shoulder, temporary total evaluation for left shoulder surgery) and October 2018 (muscle spasms, heart palpitations, heart attack, bilateral hearing loss and TDIU). In February 2019, the AOJ issued a supplemental statement of the case (SSOC) regarding all of the aforementioned issues. In a February 2019 rating decision, the AOJ granted a temporary total evaluation (100 percent) effective from September 14, 2015 to October 31, 2015 for convalescence based on the Veteran’s lumbar spine surgery. This grant constitutes a full award of the benefits sought on appeal. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). Thus, the matter is no longer in appellate status. As a preliminary matter, the Board notes that service connection for heart palpitations had initially been denied in a July 1993 rating decision. The Veteran submitted a claim in June 2013 in which he sought to reopen the claim for service connection for heart palpitations and also claimed service connection for a heart attack, to include as secondary to heart palpitations. Subsequently, in a December 2014 rating decision, the AOJ denied service connection for heart palpitations, finding that new and material evidence had not been submitted to reopen the previously denied claim. The AOJ also separately denied the initial claim for service connection for a heart attack; the Veteran timely appealed both denials. In this case, although the United States Court of Appeals for the Federal Circuit recently held in Murphy v. Wilkie, 983 F.3d 1313 (Fed. Cir. 2020) that the “lenient-claim-scope rule” of Clemons v. Shinseki, 23 Vet. App. 1 (2009) applies to requests to reopen, here, the prior denial was clearly limited to palpitations as the Veteran’s assertion that he suffered a heart attack was alleged to have occurred decades later. The Board therefore finds the Veteran’s current request to reopen applies only to the denial of service connection specifically for heart palpitations. Accordingly, in this decision, the Board will reopen the previously denied claim for heart palpitations and recharacterize the issue broadly, pursuant to Clemons, to encompass heart palpitations, heart attack, and any other heart disability that may be present. Lastly, in April 2020, the Veteran filed a motion to Advance on the Docket (AOD) due to his age. During the November 2020 Board hearing, the motion was granted by the presiding VLJ. Accordingly, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.800(c). 38 U.S.C. § 7107(a)(2). Withdrawn Claims 1. Entitlement to service connection for muscle spasms is dismissed. 2. Entitlement to an evaluation in excess of 40 percent for degenerative disk disease of the lumbar spine, status post L2 through S1 fusion (lumbar spine disability), is dismissed. 3. Entitlement to an initial compensable evaluation for bilateral hearing loss is dismissed. 4. Entitlement to a temporary total rating based on convalescence due to left shoulder surgery is dismissed. Issues 1-4. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed.  38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision by the appellant or by his or her authorized representative. 38 C.F.R. § 19.55. The withdrawal must be filed with the Board and include the name of the veteran, the applicable VA file number, and a statement that the appeal is withdrawn. If the appeal involves multiple issues, the withdrawal must specify that the appeal is withdrawn in its entirety or list the issue(s) withdrawn from the appeal. Withdrawals are effective when received by the Board if a decision has not been promulgated.  38 C.F.R. §19.55. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. Withdrawal may be made by a veteran or by an authorized representative and must be (1) explicit, (2) unambiguous, and (3) done with a full understanding of the consequences of such action by the appellant. Acree v. O'Rourke, 891 F.3d 1009, 1012 (Fed. Cir. 2018); DeLisio v. Shinseki, 25 Vet. App. 45, 5758 (2011); 38 C.F.R. § 20.205. In the present case, the Veteran (appellant) notified the undersigned VLJ who held the November 17, 2020 hearing, that he sought to withdraw his appeal for the claims of: (1) entitlement to service connection for muscle spasms, (2) entitlement to a rating in excess of 40 percent for a lumbar spine disability, (3) entitlement to an initial compensable rating for bilateral hearing loss, and (4) entitlement to a temporary total rating based on convalescence due to left shoulder surgery. This request was made with full understanding of the consequences and in consultation with his attorney. See Hearing Transcript at 2 (November 2020). Hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal of the matters and they are dismissed. Reopened Claim 5. The petition to reopen the claim for entitlement to service connection for heart palpitations is granted. The Veteran contends that his heart palpitations (fluttering) had their onset during service and were the first manifestations of his heart disabilities diagnosed many years after service. Generally, a claim that has been denied in an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C. § 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). Evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence had not been previously presented. Anglin v. West, 203 F.3d 1343, 1347 (2000). In deciding whether new and material evidence has been received, the Board looks to the evidence submitted since the last final denial of the claim on any basis. Evans v. Brown, 9 Vet. App. 273, 285 (1996). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of evidence is presumed unless the evidence is inherently incredible or consists of statements that are beyond the competence of the person or persons making them. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). Regardless of whether the RO found that new and material evidence had been submitted to reopen a claim for service connection, it is well established that the Board must determine on its own whether new and material evidence has been submitted to reopen a claim. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). The Board concludes that the July 1993 rating decision denying the claim for service connection for heart palpitations is final; and that, for the reasons discussed below, the new and material evidence has been received to reopen the claim. 38 U.S.C. §§ 5103, 5103A, 5108, 7105(c); 38 C.F.R. §§ 3.104, 3.156(a), (b), 20.1103. A July 1993 rating decision denied the claim for service connection for heart palpitations because a current disability of the heart was not shown. The originating agency noted that the Veteran’s service treatment records (STRs) did not show he had a chronic heart disability nor did a June 1993 VA general medical examination show a diagnosis of a current heart disability. VA notified the Veteran of this decision in a July 1993 letter and how to appeal. However, VA received no appeal or new and material evidence prior to expiration of the one-year appeal period. Therefore, the July 1993 rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 20.1103. Evidence associated with the claims file since the prior final disallowance includes evidence that is not cumulative or redundant and relates to an unestablished fact necessary to reopen the claim. Specifically, a private treatment record from North Fulton Hospital dated September 2015 indicates that the Veteran was diagnosed as having new onset atrial fibrillation, now converted to sinus rhythm. In addition, the Veteran’s most recent private medical records reveal he is currently diagnosed as having paroxysmal atrial fibrillation. See e.g. Medical Treatment Record-Non-Government-Facility (Northeast Georgia Medical Center) (June 2020). This evidence was not previously considered by decision-makers and tends to support the Veteran’s assertion that his in-service reports of heart palpitations were the first manifestations of his subsequently diagnosed heart disabilities. Therefore, as a prior evidentiary defect has been cured, the recent evidentiary submission is considered new and material. Accordingly, the petition to reopen the claim for service connection for heart palpitations is granted. However, as discussed below, the Board finds that remand is necessary prior to deciding the claim on its merits. REASONS FOR REMAND In remanding these matters, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran’s assertions. Neither the Veteran’s credibility nor any lack thereof should be presumed in this remand. 1. Entitlement to service connection for a heart disability, to include heart palpitations and heart attack, is remanded. The Veteran contends that symptoms of a heart disability were first manifested in service although a heart disability later diagnosed following service discharge. In addition, his attorney has advanced two alternative theories of service connection, including that the Veteran has congenital heart disease that was aggravated during service and/or that the Veteran has heart disability due to or a result of medication prescribed and taken for his service-connected hypothyroidism. See Hearing Transcript at 7-9, 18-20, 30 (November 2020); Attorney Brief (November 2020). To ensure that VA has met its duty to assist, remand is necessary to obtain a VA examination and medical opinion in this matter to clarify the Veteran’s current heart diagnoses as well as obtain an adequate medical opinion that addresses all of the Veteran’s, as well as his attorney’s, contentions and theories of entitlement to service connection. In this case, the Veteran’s STRs do not show a diagnosed heart disability, but there are several records documenting his complaints of chest pain, heart palpitations and shortness of breath. For instance, the Veteran was seen for complaints of chest pain and dyspnea in August 1976. At that time, he reported occasional dull pain that radiated down his left arm medially to his elbow and stated that he had a similar episode in June 1973; however, a contemporaneous EKG and chest x-ray were normal. Then, in March 1977, the Veteran reported recurrent episodes of chest pain and shortness of breath. The examiner noted the Veteran had episodes of precordial pain at rest which lasted about 2 hours and were not exacerbated with deep breathing or movement. An ECG and chest x-ray were normal; the examiner assessed the Veteran with probable pleurodynia, subsequently described as “suspected, not proven”, and determined there was no cardiac pathology. Furthermore, a November 1988 EKG summary notes the Veteran had sinus bradycardia (slow heart rate) at 57 minutes but the EKG was otherwise found to be normal. The Veteran’s Report of Medical History dated in November 1989 (over 40 physical) shows he checked off symptoms of shortness of breath, pain or pressure in his chest, heart palpitations and heart trouble. In the physician’s summary at the end of the report, the examiner elaborated the Veteran experienced episodes of heart palpitations as well as shortness of breath and chest pain on exertion. The Report of Medical Examination conducted in November 1989 indicates the Veteran reported high blood pressure and chest pain and further cardiac testing (stress test) was ordered. In December 1989, the Veteran was evaluated at the internal medicine clinic where it was noted that he was having heart palpitations and left chest pain, radiating to his left elbow. The symptoms were associated with shortness of breath and diaphoresis. Shortly thereafter, an internal medicine clinic entry dated February 1990 documents that cardiac testing was conducted. The examining physician noted that 24-hour Holter monitoring revealed sinus rhythm (SR) with isolated multi-focus premature ventricular contractions (PVC)(5) and isolated premature atrial complexes (PAC)(15); however, he also indicated there was no evidence of supraventricular tachycardia or runs of ventricular tachycardia. Moreover, the physician found the Veteran’s graded exercise test (GXT) was normal. Based on the foregoing test results, the Veteran was assessed with atypical chest pain that the doctor concluded was probably gastrointestinal in nature and heart palpitations that he indicated may have been related to excessive doses of Synthroid, citing a December 1989 STR in which the Veteran’s thyroid medication was adjusted. The Veteran’s Report of Medical History at separation dated September 1992 shows he endorsed symptoms of chest pain for the past 10 years and heart palpitations. The Report of Medical Examination conducted in September 1992 showed a normal EKG, chest x-ray, and clinical examination of the heart. The Veteran underwent a VA heart conditions examination in October 2018. The examiner found the Veteran had diagnoses of stable angina, valvular heart disease, cardiomyopathy and coronary artery disease and opined that his claimed conditions (heart attack and heart palpitations) were less likely than not incurred in or caused by an in-service injury, event or illness. The VA examiner concluded that an October 2018 EKG report showing a possible anterior myocardial infarction was an incidental finding and thus, did not warrant a diagnosis. She further stated that the remaining evidence did not show the Veteran had previously suffered a heart attack. The VA examiner additionally concluded that the Veteran’s complaints of heart palpitations were limited to his military service, and evidence following service was negative for heart palpitations with the exception of a private medical record dated September 2015 from North Fulton Hospital documenting atrial fibrillation two days following lumbar spine surgery that had resolved a few days later, prior to discharge. For a number of reasons, the Board finds the VA examination and medical opinion inadequate for adjudicative purposes. First, the VA examiner focused her opinion solely on whether the record supported a diagnosis of a myocardial infarction/heart attack and whether the record showed the Veteran currently had heart palpitations or atrial fibrillation. However, she failed to address whether the Veteran’s currently diagnosed heart disabilities (i.e. stable angina, valvular heart disease, cardiomyopathy and coronary artery disease) were first manifested during the Veteran’s active service or otherwise etiologically related to service along with whether coronary artery disease manifested within one year after service discharge. Here, the examiner appears to have simply attributed the Veteran’s in-service symptoms such as chest pain and heart palpitations to in-service hypertension (see discussion in following paragraph), while relating his coronary artery disease and stable angina to atherosclerosis and his valvular heart disease to calcium build-up/calcification. Hence, the examiner essentially provided bare conclusory statements without articulating a rationale for her findings. It is noted that a medical opinion or "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). The Board finds there are additional deficiencies with the October 2018 medical opinion which render it inadequate for adjudication purposes. For instance, the examiner indicated the Veteran’s current cardiomyopathy was caused by hypertension and also determined the Veteran had hypertension in service, yet she failed to comment on whether there was any relationship between the Veteran’s cardiomyopathy and his in-service hypertension. As to the examiner’s conclusion that hypertension was shown during service, the Board notes that other than the VA examiner’s reference to an August 1976 STR documenting blood pressure readings of 142/100 and 126/100 (indicative of diastolic hypertension according to the examiner), there is no medical basis for her finding that hypertension occurred during service. In fact, the Board notes that to the extent the STRs show some elevated blood pressure readings and the Veteran self-reported experiencing high blood pressure during his November 1989 Report of Medical Examination, he was not diagnosed with hypertension during service or in the years immediately following his separation from service. See e.g. VA treatment record containing a review of systems reflecting the Veteran was negative for hypertension. (VA Clinic, Greenville, NC) (December 1999). Finally, the medical opinion is inadequate because it does not address the clinical significance, if any, of the abnormal test results, discussed above, from the 24-hour Holter monitoring and whether within the context of the Veteran’s in-service complaints of heart palpitations, these were early manifestations of cardiac arrhythmia. Next, the Board notes that the Veteran’s VA and non-VA medical records reflect a complex cardiac history involving a myriad of heart diagnoses and related surgical procedures. In particular, the Veteran’s most recent private medical records from The Heart Center of Northeast Georgia Medical Center, dated from 2020, demonstrate that his cardiac profile has significantly changed since his VA heart examination in October 2018. For instance, while the VA examiner determined the record was negative for evidence of a heart attack, a private medical record from The Heart Center dated in May 2020, reflects the Veteran suffered cardiac arrest and third-degree heart block requiring the placement of a biventricular pacemaker in April 2020. In addition, although the VA examiner stated the Veteran was not shown to have atrial fibrillation, another medical record dated in June 2020 shows he has been diagnosed as having paroxysmal atrial fibrillation. Lastly, a medical record dated in April 2020 refers to a “likely congenital bicuspid aortic valve with severe aortic stenosis” which tends to support the Veteran’s hearing testimony that his doctor informed him he had a congenital heart condition. See Hearing Transcript at 11 (November 2020). Given the foregoing, the Board finds that remand is necessary to obtain an additional VA examination to clarify the Veteran’s current heart diagnoses, determine the nature and etiology of his various heart disabilities and address the multiple theories of entitlement to service connection advanced by the Veteran and his attorney. In determining the adequacy of a medical examination or opinion, an examination or opinion is considered adequate, "where it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's '"evaluation of the claimed disability will be a fully informed one.'" Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (quoting Ardison v. Brown, 6 Vet. App. 405, 407 (1994) (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991))). 2. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities is remanded. The Veteran contends that he has neurological disabilities (variously diagnosed as bilateral peripheral neuropathy, sensory bilateral polyneuropathy and lumbar radiculopathy) in his right and left legs due to his service-connected lumbar spine disability. See Hearing Transcript at 4, 22-23 (November 2020). To ensure that VA has met its duty to assist, the Board finds is necessary to obtain a VA examination addressing whether the Veteran has any lower extremity neurological disability, showing during or approximate to this appeal, had its onset in service, manifested within one year after service, or is etiologically related to his service-connected lumbar spine disability. The Veteran was most recently afforded a VA peripheral nerves examination in August 2015 and was diagnosed as having sensory polyneuropathy of the bilateral lower extremities. In conjunction with the physical examination, the Veteran underwent a contemporaneous EMG study of the right and left lower extremities which showed findings consistent with chronic predominant sensory polyneuropathy affecting the bilateral feet with clinical sensory deficits. The Board notes that a negative nexus opinion was rendered by a VA clinician other than the VA physician who conducted the August 2015 examination. The clinician opined that the Veteran’s peripheral neuropathy of the lower extremities is less likely than not proximately due to his service-connected low back disability. The clinician provided a supporting rationale that the Veterans STR's show he was diagnosed with lumbar spine arthritis and scoliosis and underwent two lumbar spine surgeries, the first in 1986, with revision in 2010, decompressive laminectomy, discectomy L3-L4, L4-L5. She further noted the Veteran does not require an assistive device to aid in walking, he is able to rise and sit without difficulty, and he has a non-antalgic, non-shuffling or non-slap foot gait. He has left greater than right lateral foot decreased sensation with monofilament 5.07/10 gm. She indicated that his current EMG/NCV results showed idiopathic peripheral polyneuropathy affecting the bilateral feet. She explained that potential risk factors to the development of polyneuropathy are alcohol abuse, vitamin deficiencies, autoimmune disorders, and liver disorders. She determined the Veteran had disorders that contributed to his polyneuropathy such as a history B12 deficiency, fatty liver disorder, hemochromatosis, former alcohol abuse, and a history of Mad Cow Disease. Finally, the Board notes that the medical opinion concludes that “nerve conduction studies did not direct cause of neuropathy to his lumbar spine but yet is a combination of his current and past medical history, to direct toward one single diagnosis cannot be provided without speculation, it is the combination of all, that has likely contributed.” The Board finds the medical opinion is inadequate because the essential rationale is not discernable. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). Indeed, the rationale is confusing, inaccurately summarizes relevant medical findings, and does not appear to be based on full consideration of the entire record, including non-VA medical records reflecting diagnoses such as bilateral lower extremity radiculopathy (Resurgens Orthopedics) (July 2014). An adequate medical opinion must be “accurate and fully descriptive,” and based on an accurate factual premise and consideration of a veteran's prior medical history. Ardison v. Brown, 6 Vet. App. 405, 407 (1994). In addition, the opinion “must support its conclusions with an analysis that the Board can consider and weigh against contrary opinions.” Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); A medical opinion must contain clear conclusions with supporting data, and a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). In this case, the August 2015 VA clinician who provided the medical opinion provided none of the above, thereby rendering the opinion inadequate. If VA provides a claimant with an examination in accordance with the duty to assist, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In this case, the Veteran’s STRs and post-service medical records demonstrate inconsistent complaints, clinical findings and diagnoses pertaining to the Veteran’s neurological function in the bilateral lower extremities. For example, STRs contain numerous records showing the Veteran had complained of low back pain that radiated down his left lower extremity which corroborate the Veteran’s hearing testimony that around 1972, he first noticed lower extremity symptoms of pain, weakness and loss of feeling associated with his low back pain. However, he also testified that following service, his symptoms were intermittent. See Hearing Transcript at 25-27 (November 2020). In this regard, a private medical record from Foot and Ankle Clinic of Oakwood dated October 2013 reflects the Veteran was seen for complaints of pins and needles in his bilateral second toes which started immediately upon waking up one morning and worsened with walking. The Veteran denied any history of diabetes or aggravating issues and reported some lower back pain and a history of low back surgery. Additionally, the record contains several VA lumbar spine examination reports that have been associated with the record since the Veteran’s lumbar laminectomy in 2010, all of which contain conflicting neurological findings pertaining to the right and left lower extremities. Furthermore, one month following the Veteran’s VA peripheral nerves examination, in September 2015, he underwent L2 through S1 transforaminal lumbar interbody surgical fusion with posterolateral fusion. A few years later, the Veteran’s private physician noted he experienced moderate radiculopathy or sciatic pain secondary to his low back condition stemming from L4-L5. (Medical Treatment Record-Non-Government Facility) (Dr. Otto Goyco) (January 2018). Subsequently, a VA back conditions examination conducted in May 2018 showed the Veteran did not have any neurologic abnormalities or radiculopathy related to his low back condition. In fact, upon physical examination, the Veteran was found to have negative straight leg raising and normal sensory, muscle strength and reflex clinical findings in both lower extremities. Therefore, although the Board recognizes the Veteran submitted several medical records from his non-VA providers reflecting diagnoses of lumbar radiculopathy or peripheral neuropathy of the bilateral lower extremities due to his low back disability, the diagnoses are not associated with any diagnostic nerve testing such as an EMG, nor are they based on a fully informed review of the Veteran’s claims file, particularly given the conflicting medical of record described above. See Stefl, supra; Nieves-Rodrigeuz, supra. Because the VA and non-VA medical records contain inconsistent findings as to whether the Veteran has any neurological disabilities in his right and left legs due to his service-connected lumbar spine disability, the Board finds that an updated VA examination and adequate medical opinion are required to reconcile the varied neurological findings in this case. 3. Entitlement to service connection for a left shoulder disability is remanded. 4. Entitlement to service connection for a left ankle disability is remanded. 5. Entitlement to a TDIU is remanded. Issues 3-5. The Veteran asserts that his current left shoulder and left ankle disabilities are the result of injuries sustained from approximately four falls (2 severe) caused by numbness and weakness in his lower extremities from lumbar radiculopathy. See Hearing Transcript at 5, 22-23 (November 2020). The record shows the Veteran underwent left rotator cuff surgery in 2013 and he testified that he continues to have pain in his left ankle stemming from a fractured ankle after he fell down some stairs and hit a wall. See Hearing Transcript at 6-7. On the Veteran’s Application for Increased Compensation based on Unemployability (VA Form 21-8940), received in June 2013, he stated that as a result of not feeling his feet, he has fallen down steps four times causing a left shoulder injury and left foot sprain and fracture. The Veteran also contends that his disabilities (service-connected and nonservice-connected at this time) render him unable to secure or follow a substantially gainful occupation. The Veteran’s VA Form 21-8940 reflects that he completed four years of high school, last worked full time in March 2009 as a customs inspector and indicated that he was unable to work due to the severity of his low back disability, pain and weakness in his lower extremities and his heart disabilities. However, during the Veteran’s Board hearings, he also indicated that he stopped working to help care for his wife who had medical issues and not due to any of his disabilities. See e.g. Hearing Transcript at 16-18 (November 2020). The Board finds the Veteran's claims for service connection for a left shoulder disability, left ankle disability and entitlement to TDIU are inextricably intertwined with the claims for service connection being remanded herein. Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). Therefore, adjudication is deferred pending the outcome of the claims. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for all non-VA medical providers, to include Dr. Otto Goyco and Resurgence Orthopedics Group, seen for treatment related to his heart disabilities, peripheral neuropathy of the bilateral lower extremities, left shoulder disability and left ankle disability. Make two requests for the authorized records from all identified sources, unless it is clear after the first request that a second request would be futile. 2. Schedule the Veteran for an examination by an appropriate clinician, such as a cardiologist, to determine the nature and etiology of his heart disabilities. The entire claims file, to include a copy of this remand, should be made available to and reviewed by the examiner. Detail the Veteran’s reported symptoms in service and thereafter, including the nature, onset, progression and severity of his reported symptoms. If there is any medical reason to accept or reject the proposition that his reported symptoms in service and thereafter represent the onset of any current heart disability in service, this should be noted. Consideration should be given to (a) cardiac testing including EKG, ECG, 24-hour Holter monitoring, exercise stress tests, chest x-rays and blood tests conducted during service and (b) complaints of chest pain, shortness of breath, and heart palpitations in service. The examiner is asked to address the following: (a) Identify all heart disabilities shown since roughly 2013 (i.e. approximate to the filing of this claim). The examiner should also consider the diagnoses rendered by the Veteran’s VA and non-VA medical providers. If any previously diagnosed heart disabilities are not found on examination, the examiner should address whether they were misdiagnosed or resolved. (b) Explain whether any currently diagnosed heart disability is considered a congenital disease or a congenital defect. Congenital diseases are capable of progression as opposed to congenital defects which are static in nature and incapable of improvement or deterioration. (c) If any heart disability constitutes a congenital disease, opine as to whether the disability at least as likely as not was permanently aggravated beyond its normal progression by the Veteran’s service. (d) If any heart disability constitutes a congenital defect, opine whether the Veteran has an additional disability due to an in-service disease or injury superimposed upon such defect. (e) Opine whether it at least as likely as not each diagnosed heart disability: (i) manifested during active service; or (ii) manifested within one year after discharge from service, or (iii) was noted during service with continuity of the same symptomatology since service, or (iv) is otherwise causally or etiologically related to active service injury or disease, to include complaints of chest pain, shortness of breath and heart palpitations. (f) Opine whether any diagnosed heart disability is at least as likely as not (i) proximately due to or (ii) aggravated by the Veteran’s service-connected hypothyroidism, to include any prescribed medication. The opinion should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. 3. Schedule the Veteran for an examination by an appropriate clinician or specialist such as a neurologist, to determine the nature and etiology of any neurological disabilities, including peripheral neuropathy, peripheral polyneuropathy and lumbar radiculopathy, present in his bilateral lower extremities. The entire claims file, to include a copy of this remand, should be made available to and reviewed by the examiner. The examiner is advised that (a) the Veteran is currently service-connected for degenerative disk disease of the lumbar spine, status post L2 through S1 fusion and (b) he contends that his neurological symptoms in his bilateral lower extremities first manifested during service and are due to his low back disability. Detail the Veteran’s neurological symptoms in his lower extremities during service and since service. The examiner is asked to address the following: (a) Identify all current neurological disabilities of the right and left lower extremities. The examiner should also consider the diagnoses rendered by the Veteran’s VA and non-VA medical providers, to include VA lumbar spine examiners and the VA peripheral nerves examiner. If any previously diagnosed peripheral nerve disabilities of the bilateral lower extremities, including peripheral neuropathy, sensory polyneuropathy and lumbar radiculopathy, are not found on examination, the examiner should address whether they were misdiagnosed or resolved. (b) Opine on whether it at least as likely as not each diagnosed neurological disability of the bilateral lower extremities: (i) manifested during active service; or (ii) manifested within one year after discharge from service, or (iii) was noted during service with continuity of the same symptomatology since service, or (iv) is otherwise causally or etiologically related to active service injury or disease, to include symptoms of pain, numbness and tingling in the left lower extremity. (c) Opine whether any diagnosed neurological disability of the bilateral lower extremities is at least as likely as not (i) proximately due to or (ii) aggravated by the Veteran’s service-connected lumbar spine disability. The opinion should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. 4. Ensure that the VA medical opinions obtained include a complete rationale for the conclusions reached. The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include 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. (Continued on the next page) C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals THOMAS H. O'SHAY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Krunic, 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.