Citation Nr: 21013576 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 20-14 699 DATE: March 9, 2021 REMANDED Entitlement to service connection for lumbosacral strain is remanded. Entitlement to service connection for sleep disorder to include sleep apnea, anxiety and depression is remanded. Entitlement to service connection for neuropathy of the right lower extremity is remanded. Entitlement to service connection for neuropathy of the left lower extremity is remanded. Entitlement to service connection for neuropathy of the right upper extremity is remanded. Entitlement to service connection for neuropathy of the left upper extremity is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1966 to October 1968. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In January 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A copy of the transcript is associated with the evidentiary record. The Board notes that while the Veteran’s video hearing was terminated due to a loss internet connection, in a January 2021 statement, the Veteran’s representative has asserted that the hearing was complete at the time that the connection was lost. Accordingly, the Board will move forward with assessing the Veteran’s appeals on the merits. A claimant is not required in filing a claim for benefits to identify a precise medical diagnosis or the medical cause of his condition; rather, he sufficiently files a claim for benefits “by referring to a body part or system that is disabled or by describing symptoms of the disability.” Id. at 86. This is because a claimant is not expected to have medical expertise and generally “is only competent to identify and explain the symptoms that he observes and experiences.” Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence of laypersons to testify as to symptoms but not medical diagnosis). The Board has thus expanded the scope of the Veteran’s claim regarding entitlement to service connection for issues regarding his sleep. For the reasons discussed below, each of the Veteran’s claim must be remanded for VA examinations. VA is obligated to provide an examination when the record contains (1) competent evidence of a current disability (or persistent or recurrent symptoms of a disability), (2) evidence establishing that an event, injury, or disease occurred in service, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service, but (4) there is insufficient competent medical evidence on file to decide the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 1. Entitlement to service connection for lumbosacral strain is remanded. With respect to the Veteran’s claims for entitlement to service connection for lumbosacral strain, the Veteran testified that he injured his back in service during basic training and continues to suffer from back pain. Consistent with the Veteran’s contentions service treatment records show that the Veteran reported myalgias in his legs and back in March 1986, in service. Post service, a February 2000 imaging of the Veteran’s spine notes degenerative disc disease throughout the spine. Nonetheless, the Veteran was never afforded a VA examination for his lumbar spine. Based on evidence of a current disability and an in-service injury, remand is warranted for a VA examination and an opinion regarding the etiology of the Veteran’s lumbar spine disability. 2. Entitlement to service connection for sleep disorder to include as due to sleep apnea, anxiety and depression is remanded. At his hearing the Veteran contends that he developed a sleep disorder in service, with symptoms including difficulty sleeping and nervousness. The Veteran further testified that post service he was referred to a psychiatrist who diagnosed him with depression and prescribed medication for his sleep disorder. He also reported that he was referred to group therapy. Additionally, the Veteran asserted that in the 1970’s he was diagnosed with sleep apnea and prescribed a CPAP machine which was not helpful. Consistent with the Veteran’s contentions, service treatment records show that the Veteran reported night sweats in service. Post service, May 2007 private treatment records note that the Veteran reported difficulties with sleep and may have sleep apnea. July 2009 private treatment records note a past medical history for sleep apnea and depression with insomnia. May 2016 private treatment records notes that the Veteran has obstructive sleep apnea. Given that the record contains evidence of a current sleep disability and the Veteran has testified to an in service injury or event with supporting evidence from service treatment records, remand is warranted for a VA examination and etiology opinion related to the Veteran’s claim for entitlement to service connection for a sleep disorder. The Board also notes that during his hearing, the Veteran testified to receiving some private treatment for his disabilities in the 1970s including mental health treatment and being prescribed a CPAP. This evidence is not present in the record. Remand is required to undertake development to secure any outstanding private treatment records pertaining to the Veteran’s claims. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c) (2019). This includes making reasonable efforts to obtain relevant private medical records. 38 C.F.R. § 3.159(c)(1). 3. Entitlement to service connection for neuropathy of the right lower extremity is remanded. 4. Entitlement to service connection for neuropathy of the left lower extremity is remanded. 5. Entitlement to service connection for neuropathy of the right upper extremity is remanded. 6. Entitlement to service connection for neuropathy of the left upper extremity is remanded. The Veteran contends that his neuropathy of his bilateral upper and lower extremities is a result of daily exposure to chlorinated hydrocarbon in service. Specifically, during his hearing the Veteran testified that as a part of his military occupational specialty in service as a repair technician he used chlorinated hydrocarbon to clean equipment daily for approximately one year in service. The Veteran further asserted that he did not wear protective gear while cleaning the equipment. Consequently, he began to notice numbness in his lower extremities and later noticed numbness in his fingers. He also reported that he lost coordination of his hands. Post service, private treatment records note diagnosis of sensorimotor polyneuropathy and bilateral carpal tunnel syndrome. The Veteran has not been afforded VA examinations for his claims for entitlement to service connection for neuropathy of the bilateral upper and bilateral lower extremities. As such, remand is warranted for a VA examination and etiology opinion. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for all outstanding private treatment records, including records from the 1970s and thereafter. Make two requests for the authorized records from, unless it is clear after the first request that a second request would be futile. All efforts to obtain outstanding private treatment records should be well documented in the file. 2. Obtain the Veteran’s VA treatment records for the period from January 2020 to present. 3. Schedule the Veteran for a VA examination for his back disability. The examiner must review the claims file. The examiner is asked to provide a response to the following: Is the Veteran’s lumbar spine disability at least as likely as not related to service, including the Veteran’s complaint of myalgias in service? Provide a rationale to support the opinion(s). 4. Schedule the Veteran for a VA examination for his sleep disorder. The examiner must review the claims file. The examiner is asked to provide a response to the following: (a) Identify any disabilities the Veteran has that are related to or include associated symptoms of sleep disorder including but not limited to sleep apnea, anxiety and or depression. (b) Is the Veteran’s sleep disability at least as likely as not related to service, including the Veteran’s complaint of myalgias and the Veteran’s contentions that he began to have difficulty sleeping and night sweats in service? Provide a rationale to support the opinion(s). 5. Schedule the Veteran for a VA examination for bilateral upper extremity neuropathy. The examiner must review the claims file. The examiner is asked to provide a response to the following: Is the Veteran’s bilateral upper extremity neuropathy at least as likely as not related to service, including the Veteran’s statements that he was exposed to chemicals in service which resulted in neuropathy. Provide a rationale to support the opinion(s). 6. Schedule the Veteran for a VA examination for bilateral lower extremity neuropathy. The examiner must review the claims file. The examiner is asked to provide a response to the following: Is the Veteran’s bilateral lower extremity neuropathy at least as likely as not related to service, including the Veteran’s statements that he was exposed to chemicals in service which resulted in neuropathy. (Continued on the next page)   Provide a rationale to support the opinion(s). Jennifer White Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Wimbish, 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.