Citation Nr: 21011282 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 12-08 708 DATE: March 1, 2021 REMANDED A rating in excess of 10 percent for right ilioinguinal neuralgia, postoperative repair is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1974 to December 1977. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a September 2010 rating decision. This issue was denied in a January 2015 Board decision. The Veteran appealed that decision to the U.S. Court of Appeals for Veterans Claims (Court). In February 2016, the Court issued a Joint Motion for Partial Remand. A July 2016 Board decision remanded the matter for an addendum medical opinion. Thereafter, a December 2017 Board decision denied the issue. The Veteran again appealed to the Court. The Court issued a November 2018 Joint Motion for Remand. The matter was remanded again by the Board in August 2019 and October 2020. It is now before the undersigned. Unfortunately, the Board finds that further development is needed before it can proceed with adjudication. As stated above, the Board remanded this matter in October 2020 for further development. However, remand is again needed to comply with the October 2020 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The October 2020 Board remand directed the VA examiner to do the following: Identify all nerves affected by complete or incomplete paralysis, neuritis, or neuralgia. In doing so, please specifically discuss the April 2010 through May 2012 treatment records documenting the diagnoses of and treatment (such as multiple nerve blocks) for right ilioinguinal and genitofemoral nerve neuralgia, as well as the symptoms he has described since 2009, including pain in the right groin that radiates to the right testicle, flank, and medial and anterior thigh, and a tingling sensation from the groin to the medial thigh. If it is determined that the April 2010 and May 2012 diagnoses of ilioinguinal and genitofemoral nerve neuralgia do not confirm neurologic residuals of the Veteran’s bilateral hernia repair that involve two or more separate nerves, explain why that is so with complete rationale. In other words (even if current involvement of the genitofemoral nerve if not shown), explain whether April 2010 to May 2012 treatment records shows that the exhibited symptoms and treatment establish that only the ilioinguinal nerve was then involved (warranting a finding that the diagnoses of right genitofemoral neuralgia then made were invalid). Cite to the clinical findings that support the opinion and reasoning provided. For each nerve affected by incomplete paralysis, neuritis, or neuralgia, state the severity of that condition and explain the medical basis for the classification. Also explain what limitation of motion and other function, if any, is caused by the paralysis of each affected nerve. For each nerve found to be affected by complete or incomplete paralysis, neuritis, or neuralgia related to the Veteran’s bilateral inguinal hernias, postoperative repair, what is the historical degree of impairment since 2009 due to that nerve? The October 2020 VA examiner provided a short opinion that focused on the 2017 VA examination by Dr. A. The examiner stated that Dr. A. diagnosed the Veteran as having only ilioinguinal neuralgia based on the Veteran’s symptoms, physical examination findings, and history. The examiner noted that at a 2011 pain consult, both nerves (ilioinguinal and genitofemoral) were documented by a first year resident, but the attending physician later amended it to include only the ilio-inguinal nerve. This was confirmed by an additional attending physician. Later, the Veteran’s pain was still present, so the pain clinic included the genitofemoral nerve to see if it would be clinically diagnostic. The Veteran reported to only then consent to ilioinguinal injections since it was helpful, not the genitofemoral nerve. The pain clinic initially thought it was only the ilioinguinal nerve, then thought the genitofemoral nerve was possibly involved, but radiofrequency ablation of that nerve was ineffective, so it is plausible symptoms not thought to be generated from that nerve. The Veteran’s neuralgia was evaluated in 2017 by Dr. A. and confirmed the nerve causing his pain is consistent with only the right ilioinguinal nerve, and not both, with no involvement of the genitofemoral nerve. After reviewing Dr. A.’s documentation and the documentation of the pain clinic, the examiner has no reason to disagree with Dr. A.’s assessment. The Board finds that the October 2020 examiner did not address the symptoms the Veteran has described since 2009, including pain in the right groin that radiates to the right testicle, flank, and medial and anterior thigh, and a tingling sensation from the groin to the medial thigh. The examiner did not cite to any clinical findings that support his opinion that involvement of the genitofemoral nerve was not shown. He relied on the January 2017 VA examiner’s findings. However, the Court found in its November 2018 Joint Motion for Remand that the January 2017 VA examination was inadequate, as the January 2017 VA examiner failed to explain why the neurologic residuals of the bilateral hernia repair only involved a single nerve, and he does not explain how he ruled on the right genitofemoral neuralgia. Further, the examiner did not state the severity of the condition of each nerve affected by incomplete paralysis, neuritis, or neuralgia, nor the historical degree of impairment since 2009 due to that nerve. As such, remand is required to comply with the October 2020 remand directives. The matters are REMANDED for the following action: 1. Obtain updated VA and non-VA treatment records. 2. Obtain an addendum opinion, by a different clinician than the October 2020 VA examiner, to determine the severity of the Veteran’s right ilioinguinal neuralgia and a possible separate rating for a genitofemoral neuralgia. Schedule the Veteran for an examination at the discretion of the clinician. The entire record must be reviewed by the clinician. The clinician should: (a) Identify all nerves affected by complete or incomplete paralysis, neuritis, or neuralgia. In doing so, please specifically discuss the April 2010 through May 2012 treatment records documenting the diagnoses of and treatment (such as multiple nerve blocks) for right ilioinguinal and genitofemoral nerve neuralgia, as well as the symptoms he has described since 2009, including pain in the right groin that radiates to the right testicle, flank, and medial and anterior thigh, and a tingling sensation from the groin to the medial thigh. If it is determined that the April 2010 and May 2012 diagnoses of ilioinguinal and genitofemoral nerve neuralgia do not confirm neurologic residuals of the Veteran’s bilateral hernia repair that involve two or more separate nerves, explain why that is so with complete rationale. In other words (even if current involvement of the genitofemoral nerve is not shown), explain whether April 2010 to May 2012 treatment records shows that the exhibited symptoms and treatment establish that only the ilioinguinal nerve was then involved (warranting a finding that the diagnoses of right genitofemoral neuralgia then made were invalid). Cite to the clinical findings that support the opinion and reasoning provided. The examiner may not rely on the rationale provided by the January 2017 VA examiner in rendering this opinion, as this rationale has been found inadequate. (b) For each nerve affected by incomplete paralysis, neuritis, or neuralgia, state the severity of that condition and explain the medical basis for the classification. Also explain what limitation of motion and other function, if any, is caused by the paralysis of each affected nerve. (c) For each nerve found to be affected by complete or incomplete paralysis, neuritis, or neuralgia related to the Veteran’s bilateral inguinal hernias, postoperative repair, what is the historical degree of impairment since 2009 due to that nerve? (Continued on the next page)   The addendum opinion must include a complete rationale with clear conclusions and supporting data for any opinion provided. If the provider cannot provide the requested opinion without resort to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The provider should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does lacks the knowledge or training needed). Tiffany Dawson Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board I. Kerner, 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.