Citation Nr: 21016142 Decision Date: 03/19/21 Archive Date: 03/19/21 DOCKET NO. 17-02 103 DATE: March 19, 2021 REMANDED Entitlement to service connection for bilateral lower extremity (BLE) venous insufficiency is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1966 to August 1968. In January 2019, the Board, in pertinent part, remanded the above issue for additional development. In addition to the above issue, the Veteran also perfected an appeal regarding entitlement to a total disability based on individual unemployability (TDIU). However, such issue was granted in full by the Agency of Original Jurisdiction (AOJ) in January 2021. As this constitutes a full grant of the benefit sought with respect to this issue, this matter is no longer in appellate status. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997). In a separate July 2020 decision, the Board remanded the issue of entitlement to service connection for a left knee disorder. That issue is still undergoing development with the AOJ and has not yet been returned to the Board. As such, that issue will be the subject of a separate Board decision at a later date. The Board also notes that the Veteran submitted a timely November 2020 VA Form 10182 (Notice of Disagreement) to the October 2020 rating decision that denied service connection for sleep apnea. As that has been docketed under the AMA appeal system, it will also be the subject of a separate Board decision. Entitlement to service connection for BLE venous insufficiency is remanded. In the January 2019 remand, the Board requested that a VA examiner provide an opinion as to whether the Veteran’s left and/or right lower extremity venous insufficiency was caused or aggravated by his service-connected disorders. The Board instructed that the examiner should consider whether risk factors for venous insufficiency such as trauma (associated with the right knee and left foot disorders) might cause or aggravate the Veteran’s bilateral lower extremity venous insufficiency. The Board further instructed that a rationale for all requested opinions shall be provided. In an attempt to comply with the Board’s December 2019 remand instructions, the AOJ procured a December 2019 VA examination and medical opinion. The examiner diagnosed the Veteran with venous insufficiency and rendered a positive direct service connection nexus opinion. This opinion, however, appears to have been made in error, as the examiner explained further that trauma was a risk factor only if it involved the soft tissue and the Veteran’s in-service care for his foot trauma did not require any surgical or invasive treatment that would have traumatized the soft tissue. The examiner also rendered a negative aggravation opinion regarding whether the Veteran’s BLE was aggravated by his left foot injury or right total knee replacement and explained that the lower extremity varicosities or venous insufficiency did not develop within an expected time frame of his foot injury or surgery for his right total knee replacement. Lastly, the examiner provided a third nexus opinion indicating that the Veteran’s venous insufficiency was less likely than not proximately due to or the result of his service-connected conditions, pes planus and foot trauma. The examiner explained that the Veteran had no documented lower extremity soft tissue trauma, including blood clots or direct trauma, and no prolonged standing or sitting with any of these other medical conditions. She explained further that risk factors for venous insufficiency included age, family history, obesity, or prolonged sitting or standing and the Veteran had no history of blood clots, leg ulcers, or bleeding conditions that would complicate or aggravate his varicosities or venous insufficiency. In spite of the AOJ’s attempt at obtaining an adequate VA examination, the Board finds that the December 2019 VA examination is insufficient for rating purposes. In pertinent part, while the examiner indicated that venous insufficiency did not develop within an expected time frame, this statement is conclusory because she did not clarify what the expected time frame would be for the development of venous insufficiency following the Veteran’s left foot injury or surgery for his right total knee replacement. It is not otherwise clear how the temporal proximity is a factor in the development of venous insufficiency as it relates to the Veteran’s service-connected left foot and right knee disabilities. Furthermore, while the examiner indicated that the Veteran had no documented lower extremity soft tissue trauma and no leg ulcers, she did not otherwise reconcile these statements with the evidence indicating that the Veteran had bilateral total knee replacements, left foot osteoarthritis possibly due to old Lisfranc’s trauma, and venous stasis ulcer. Accordingly, the Board finds that remand is warranted for a new VA medical opinion consistent with the directives herein. The matter is REMANDED for the following action: Obtain a VA medical opinion from an appropriate examiner to determine the nature and etiology of the Veteran’s bilateral lower extremity venous insufficiency. The claims folder (including a copy of this remand) must be provided to and reviewed by the examiner. The examiner must provide an opinion regarding whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran’s left and/or right lower extremity venous insufficiency was caused or aggravated by his service-connected disorders, including his right knee disorder and left foot disorder. Aggravation in this context is defined as any increase in disability. In rendering the above opinion, the VA examiner should specifically consider whether venous insufficiency could be associated with the Veteran’s January 2009 left total knee replacement surgery or left foot disorder with documented severe osteoarthritis, possibly from old Lisfranc’s trauma. The examiner is also instructed to consider and discuss the STRs showing lower back pain at separation from service in May 2014 and the Veteran’s July 2014 and March 2016 claims for back pain. The examiner must also consider the Veteran’s reports that swelling in his legs started after his right knee replacement. See November 2016 DRO Hearing Testimony The examiner is advised that the Veteran is competent to report his symptoms/history and that such reports must be acknowledged and considered in formulating any opinion. If his reports are discounted, the examiner should provide a reason for doing so. A complete rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. If is determined that a physical examination is necessary to provide the requested medical opinions, such should be arranged. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Metzner, Paul 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.