Citation Nr: 21021608 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 15-45 682 DATE: April 13, 2021 REMANDED Compensation under 38 U.S.C. § 1151 for neurologic disability, to include as secondary to medication.   REASONS FOR REMAND The Veteran served on active duty from June 1970 to July 1974. This matter is on appeal from a June 2014 rating decision. In September 2018 and October 2020, the Board remanded this appeal for development. Compensation under 38 U.S.C. § 1151 for tardive dyskinesia, to include as secondary to medication. The Veteran asserts that he has tardive dyskinesia caused by neurological and psychotropic medications prescribed by VA. The Veteran reported that his prescriptions of Buspar, Divalproex, and Lisinopril were discontinued as a result of side effects that led to tardive dyskinesia. The Veteran also reported that he had been prescribed Depakote, Abilify, and Thompson mouthwash, all of which were prescribed by VA. The Veteran reported that he experienced burning, swelling, sucking, aching, and biting of the tongue, face twitching, smacking of lips, and some stuttering. The evidence shows that the Veteran was prescribed these medications by VA. He was given aripiprazole by VA Psychiatry in November 2010. He was also prescribed Depakote (August 1999 VA Primary Care); Divalproex (April 2008 VA Medication Management); Buspar (July 2013); and Prozac (January 2009). The Board could not locate a VA prescription for Thompson’s mouthwash. According to an emergency room note in December 2013, his primary care provider had “prescribed a solution called md anderson,” which caused a reaction. In March 2014, he indicated that a private (non-VA) ENT doctor prescribed mouthwash in November 2013 for “burning tongue.” Although, common knowledge is that mouthwash is available over the counter. Several critical questions remain at issue: (1) the nature of the condition, including a specific diagnosis; (2) whether a prescribed medication caused or aggravated the condition in that there was additional disability; (3) whether the diagnosis was due to carelessness, negligence, lack of proper skill, error in judgment, or a similar instance of fault on the part of VA providers, or (4) whether the diagnosis was due to an event not reasonably foreseeable. The Board last remanded the claim in October 2020 to address these questions. On remand, a VA examiner in November 2020 gave a cogent and compelling opinion as to questions (1), (3), and (4). Essentially, the VA examiner concluded that the Veteran did not have tardive dyskinesia, but did have diagnoses of a functional neurological illness (conversion disorder) and hyperkinetic dysarthria. The examiner opined that these conditions were less likely than not due to carelessness, negligence, lack of proper skill, error in judgment, or a similar instance of fault on the part of VA providers, but that the sudden onset of the functional neurological/conversion disorder could not have been foreseen. At present, these parts of the VA examiner’s opinion are presently probative and persuasive. With regard to question (2), regarding actual causation, the VA examiner’s opinion is also presently probative to the extent it addressed direct causation. On this question, the VA examiner opined that a functional neurological disorder (conversion disorder) is not caused by medication (to include, alone or in combination, aripiprazole, Depakote, Divalproex, Buspar, Prozac and and/or Thompson’s mouthwash); a functional neurological disorder (conversion disorder) is a psychiatric condition. The examiner also stated that hyperkinetic dysarthria is also not caused by medication (to include, alone or in combination, aripiprazole, Depakote, Divalproex, Buspar, Prozac and and/or Thompson’s mouthwash) and is instead associated with disorders of the basal ganglia control circuit (https://www.aphasia.org/aphasia-resources/dysarthria/). As stated, this rationale states unequivocally that the conditions are not caused by medications. Hence, it addresses direct causation. However, this opinion does not rule out or explain why the conditions could not have been aggravated by the medications. Thus, the opinion is incomplete to this extent. See, e.g., Garner v. Tran, No. 18-5865, 2021 U.S. App. Vet. Claims LEXIS 81, at *22-23 (U.S. Vet. App. Jan. 26, 2021) (citing El-Amin v. Shinseki, 26 Vet. App. 136, (2013)). The Board’s prior, October 2020 remand found that an aggravation theory was raised. The remand specifically asked the examiner to address whether a current diagnosis was “was caused by or aggravated” by a VA medication. Currently, the VA examiner’s opinion on causation cannot, without further explanation, be reasonably understood to encompass aggravation. See Walsh v. Wilkie, 32 Vet. App. 300, 306 (2020). As such, remand for a VA addendum opinion is warranted. The matters are REMANDED for the following action: Arrange for the relevant information in the Veteran’s claims folder to be returned to the examiner who conducted the November 2020 VA examination (or a suitable substitute if such examiner is unavailable), for the purpose of preparing an addendum opinion. (The need for an in-person examination should be determined by the examiner.) The examiner is asked to address whether it is at least as likely as not that the Veteran’s functional neurological illness (conversion disorder) or hyperkinetic dysarthria was aggravated to any degree by any single or combination of neurological medications, psychotropic medications (to include Depakote, Divalproex, Buspar, Prozac and apripirazole/abilify), and/or mouthwash, prescribed by VA treating providers. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Bosely, 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.