Citation Nr: 21011946 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 17-27 710 DATE: March 3, 2021 ORDER Entitlement to an increased rating in excess of 30 percent for asthma is denied. REMANDED Entitlement to service connection for a left wrist and hand disorder is remanded. FINDING OF FACT The preponderance of the evidence reflects that throughout the appeal period, the Veteran’s asthma required daily inhalational bronchodilator therapy; the evidence does not demonstrate FEV-1 of 40- to 55- percent predicted; FEV-1/FVC of 40 to 55 percent; at least monthly visits to a physician for required care of exacerbations; or intermittent courses of systemic corticosteroids. CONCLUSION OF LAW The criteria for entitlement to an increased rating in excess of 30 percent for asthma have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.97, Diagnostic Code 6602. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served as a member of the United States Army with active duty service from February 1993 to February 1996 during the Gulf War Era. In November 2019 the Board of Veteran’s Appeals (Board) remanded the Veteran’s claims for further development. In August 2015 the Regional Office (RO) in Waco, Texas granted service connection for asthma with an evaluation of 30 percent effective May 1, 2014. The RO also denied service connection for a left hand and wrist injury. The Veteran is appealing from those determinations. The Veteran testified at a Board hearing before the undersigned Veteran’s Law Judge in August of 2019. The hearing transcript has been associated with the file. Entitlement to an increased rating in excess of 30 percent for asthma. The Veteran filed a claim for service connection for asthma in May 2015. He attended a VA examination in August 2015 with regard to his asthma claim. In an August 2015 rating decision, the Veteran’s service connection for asthma claim was granted with an initial disability rating of 30 percent from May 1, 2014 Diagnostic Code (DC) 6602. The Veteran disagreed with the initial 30 percent rating and filed a timely notice of disagreement on September 14, 2015 requesting an increase rating. In October 2015 the Veteran requested that his case to be reviewed by a decision review officer (DRO). In June 2016 the Veteran was afforded a VA examination with regard to his asthma claim. In March 2017 the DRO issued a statement of the case (SOC) finding that the requirements for an initial rating in excess of 30 percent were not met. In May 2017 the Veteran filed a Form 9 appealing the DRO decision. In September 2017 the Veteran requested a hearing before the Board. In September 2017 treatment records from Dr. MS were associated with the file. The Regional Office (RO) issued a supplemental statement of the case (SSOC) in May 2017, denying an initial disability rating greater than 30 percent. The Veteran attended a hearing before the undersigned Veterans Law Judge in August 2019. When the Veteran testified at the hearing in August 2019, he explained that he felt a higher rating should be awarded for his asthma because the medications in the VA records did not reflect the seriousness of his illness. The Veteran explained further that he used his preventative inhaler more frequently and his rescue inhaler a lot more frequently. He specifically reported that he did not have any increase in his attacks. The Veteran testified further that he experienced attacks approximately twice a week depending on his work duties. The attacks lasted anywhere from 45 seconds to two minutes. The Veteran testified that the medications helped him during these attacks but stated he was also on steroid treatment from a private doctor, not from the VA. The Veteran stated that the doctor prescribed the steroid prednisone every three to six months depending on his attacks. With regard to inhalers, the Veteran testified he used the Advair 250 twice a day and during an asthma attack he needed five or six sprays from his rescue inhaler. The Veteran is required to climb in order to undertake his work and stated that often he needed to take a break when climbing and use his inhaler. In addition, he sometimes woke in the middle of the night to use his inhaler. In November 2019 the Board remanded the Veteran’s claim and requested the RO work with the Veteran to ensure that all available medical records were obtained and associated with the claims file. The RO followed up with a letter dated December 2019 requesting that the Veteran identify any additional treatment records. There is a November 2012 record that pre-dates the remand, reflecting treatment with prednisone, but another 2012 record indicated prednisone was not being taken. After the 2019 Board remand, the Veteran did not associate any medical records with the file that might offer evidence to support the Veteran’s claims. A January 2020 chest x-ray for asthma was associated with the file, but no other records. A VA examination for respiratory conditions was completed in March 2020. The examiner reflected that there was no use of corticosteroid medication and no antibiotic use. In addition, the examiner reported that the Veteran visited his doctor for asthma approximately every other month and not monthly. The examiner interpreted the January 2020 chest Xray as indicating that no active chest process was seen. With regard to functional impact, the examiner reported that upon exposure to dust, the Veteran experienced decreased ability to work outdoors due to asthma flare ups. Disability evaluations are determined by the application of a schedule of ratings based on average impairment of earning capacity. 38 U.S.C. § 1155. Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in the VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Under DC 6602, a 30 percent rating is warranted when pulmonary functioning reveals an FEV-1 of 56 to 70 percent predicted, or; an FEV-1/FVC of 56 to 70 percent; or when there is daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication. A 60 percent rating is warranted when pulmonary functioning reveals an FEV-1 of 40 to 55 percent of predicted, or; FEV1/FVC of 40 to 55 percent; or if there are at least monthly visits to a physician for required care of exacerbations, or; intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. Finally, a 100 percent rating is warranted when pulmonary functioning reveals an FEV-1 less than 40 percent predicted, or; FEV-1/FVC less than 40 percent, or; more than one attack per week with episodes of respiratory failure, or; requires daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications. The March 2020 examiner reflected that the Veteran is not required to use oral or parenteral corticosteroid medications. An examination or opinion is adequate if it is thorough and contemporaneous, considers the Veteran’s prior medical examinations and treatment, and describes the disability 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). On close review, the Board finds that the March 2020 VA examination did address the relevant facts and the severity of the Veteran’s service-connected asthma. The examiner considered the Veteran’s lay assertions as well as various pieces of evidence from the medical records in support of the findings. The examination includes findings sufficient to rate the Veteran’s asthma under the appropriate diagnostic code. Having reviewed the record, the Board finds that the evidence is against an evaluation in excess of 30 percent during the period on appeal. The March 2020 medical report indicates that the Veteran’s FEV-1 and FEV-1/FVC results were greater than 70 percent of the predicted value. A review of the medical records does not reflect symptomatology that warrants a higher evaluation. There were no documents indicating that the Veteran visited a physician at least monthly due to exacerbations and no treatment documents supporting a course of systemic corticosteroids. See 38 C.F.R. § 4.97, DC 6602. In reaching its determination, the Board has considered the Veteran’s lay statements. However, the Veteran’s lay assertions lack sufficient detail to warrant a higher evaluation for his asthma. Thus, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 30 percent for the Veteran’s service-connected asthma, and the claim must be denied. 38 U.S.C. § 1155 (b); 38 C.F.R. § 4.97, DC 6602. REASONS FOR REMAND Entitlement to service connection for a left wrist and hand disorder. The Veteran contends that he suffers from a current left hand and wrist disability that occurred while he was in active service. He reports that his initial left hand and wrist injury happened in an automobile accident and he was treated at the military hospital in Fort Bragg. He was injured again while serving in Haiti. The Veteran contends that he continues to experience joint pain in his left wrist and left fifth finger, and the disorder interferes with some aspects of his current employment because the disability interferes with his ability to open and close valves. Under the relevant laws and regulations, service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Generally, the evidence must show (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). In November 2019, the Board remanded the Veterans left hand and wrist claim in order to obtain a VA examination and medical opinion. The Veteran was afforded the examination in March 2020. The Veteran suffers from a present disability of his left hand and wrist. In March 2020 a VA medical examiner interviewed and examined the Veteran with regard to his claimed left wrist and hand disability. The examiner listed the diagnosis as “other diagnosis number one”: left wrist fracture. Date of diagnosis the examiner lists as 1993. The report related that the Veteran was involved in a car wreck injuring his left wrist, diagnosed with a fracture and placed in a cast. The Veteran stated he has experienced intermittent left wrist pain since the injury. The course of condition since onset is that it has improved. Current symptoms are listed as the Veteran complaining of intermittent left wrist pain while turning valves on the tanks at work or performing repetitive heavy lifting activities. The Veteran also reported flare ups and functional loss or functional impairment of the joint which manifested as a decreased ability to turn valves or perform repetitive heavy lifting activities. The range of motion of the left wrist was recorded as normal range. The examiner noted pain upon examination in the range of motion ulnar deviation. There was objective evidence of localized tenderness and pain on palpitation. This tenderness occurred at the distal left ulna and the examiner reported it is mild and it is the residual of fracture. There was evidence of pain with weight bearing. There was no evidence of crepitus. The examiner opined that the examination was medically consistent with the Veteran’s statement describing functional loss with repetitive use over time. Pain was a factor that caused functional loss with repeated use over a period of time. The examiner did not reflect any remarks or diagnosis with regard to arthritis or the Veteran’s self-report regarding bones “popping out”. The March 2020 VA examiner ultimately provided both a positive and a negative nexus opinion. While the examiner denied service connection (negative nexus opinion), the examiner also described a positive nexus because the examiner’s medical report states that the Veteran’s current disability originated from the Veteran’s injury in service. The examiner listed the Veteran’s current diagnosis as left wrist fracture and recorded the date of diagnosis as 1993. Records support that the Veteran suffered from in service injuries of the left hand and wrist. The service treatment records (STR’s) reflect that his left hand and wrist were x-rayed, and he received treatment in service pursuant to “MVA”: presumed to abbreviate “motor vehicle accident”. The Veteran reported that the injuries occurred in service when he was headed back to his barracks to get his clothes and be ready for duty the next morning, and an automobile accident happened right in front of his barracks. See Hearing Transcript dated August 2019. As he was leaving his barracks, another solider ran a red light in an automobile and T-boned him. The impact pushed the steering wheel through the dashboard, causing the Veteran’s injuries. He was taken to a military hospital which was in Fort Bragg where x-rays were undertaken. The Veteran reported that his thumb was broken and his knuckle and wrist were swollen. When receiving his half cast, he was told not to do any heavy lifting. He was told he would have to see a doctor to get the half cast off in six weeks. On the Form 9 dated September 2015 the Veteran stated: I broke my hand on post. Had to go on post medical clinic to get second x-ray that showed knuckle was crushed and wrist was fractured. My hand was fractured during an accident on Fort Bragg. The Veteran reported that he injured his left wrist again in Haiti. The Veteran was driving a five ton dump truck at night on a mission. Another vehicle was impacted either by a gunshot through the windshield or hit a landmine. The event caused the other vehicle to swerve and hit the five-ton dump truck that the Veteran was driving. The mirror exploded, knocking him out, and he reinjured his wrist holding the steering wheel, trying to keep him from going forward in the truck. After the incident in Haiti, he did not have a cast. He talked to his platoon sergeant that morning and told him his wrist was still really sore. The only medical professionals that he saw during his accident was when he was going in and out of consciousness while they were washing glass out of his face and trying to pull some out with tweezers. The Veteran reported after separation from service that his hand and wrist disability affected his job because it takes him longer to do his work duties. In addition, if he sleeps on his wrist, the pain causes him to waken in the middle of the night. After separating from service, the Veteran testified that a treating physician told the Veteran that he probably suffers from arthritis due to the bones he broke in service. The doctor prescribed pain medication but did not conduct any x-rays or any further tests. The doctor only treated the symptoms. The Veteran also testified that sometimes his bones in the affected area “pop out of place”. A December 2009 VA treatment record showed the Veteran complained of joint pain in his left wrist and left fifth finger on his hand which the Veteran reported was due to a motor vehicle accident. With regard to the Veteran’s left hand and wrist during service, the Board finds the Veteran’s statements credible with regard to his descriptions of the two accidents and the injuries he incurred to his left hand and wrist while in active service. See 38 C.F.R. § 3.159(a)(2); Barr, 21 Vet. App. at 307-09. In addition, the March 2020 VA examiner acknowledged a connection to the Veteran’s service because the examiner stated that the Veteran suffered from current symptoms in his left hand and wrist identified as a left wrist fracture with a date of diagnosis listed as 1993. Unfortunately, the March 2020 examination is not adequate in several respects, including the examiner’s omission of any discussion of the Veteran’s contentions regarding arthritis and his bones popping, in addition to other symptoms that were not addressed by the examiner. The Board regrets the additional delay, but finds it is necessary to remand the Veteran’s claim. A VA medical examination is required in order to determine the nature and etiology of the Veteran’s left wrist and hand disability, and to specifically address the Veteran’s claims regarding arthritis, bones popping out of place, and ongoing symptoms. When the Board remands an appeal, the claimant obtains a right to compliance with the remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In addition, the Board requires a well-reasoned nexus opinion that considers all of the information in the Veteran’s claims file in order to evaluate the Veteran’s claim.   The matters are REMANDED for the following action: 1. Schedule the Veteran with an examiner having appropriate expertise with regard to the Veteran’s left hand and wrist disability. The VA examiner should review the details set forth in this remand, the entirety of the claims file, the history presented by the Veteran in testimony and statements, and examination results. The examiner should reflect that this required review was accomplished. All fields on the appropriate examination form should reflect either a reasoned response or an indication that the field is not applicable. The examiner should provide a complete rationale thoroughly explaining the medical reasons for all opinions offered. All indicated testing should be accomplished and all symptomatology associated with the left hand and wrist disorder should be identified. The examiner is specifically directed to the Veteran’s contention that his left wrist and hand disorder should include a diagnosis of arthritis and “bones popping out”. The examiner should conduct any and all x-rays and diagnostic tests required in order to address the contentions, render any and all appropriate diagnoses, and explain the nature and etiology of the Veteran’s described disorders to include suggestions of arthritis and “bones popping out”. The examiner should provide a complete rationale thoroughly explaining the medical reasons for all opinions offered. 2. The RO must ensure that the left wrist and hand examination report is in compliance with the directives of this remand. If any report or opinion is deficient in any manner, the RO must implement corrective procedures. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.M. Schneider 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.