Citation Nr: 21021741 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 16-15 856 DATE: April 13, 2021 REMANDED Entitlement to service connection for a tremor disorder is remanded. REASONS FOR REMAND The Veteran served with the United States Army from November 1968 to January 1970, including foreign service. This matter was previously remanded by the Board of Veterans’ Appeals (Board) in June 2019. The Board’s remand directives and the subsequent actions of the AOJ will be discussed below. The Veteran’s appeal has been returned to the Board for further appellate consideration. Entitlement to service connection for a tremor disorder is remanded. The Board previously remanded this matter in June 2019 for additional development, including a VA examination. Regarding the VA examination, the examiner was directed to opine 1) whether the Veteran’s tremors were a symptom of another disorder, such as Parkinson’s disease, 2) whether a tremor disorder was caused by any in-service event, disease, disorder, or injury or in any way originated during service, including as a result of presumed exposure to herbicide agents, 3) whether a tremor disorder was caused by any service-connected disorder or treatment thereof, including as a result of any medications taken to treat another disorder, and 4) whether a tremor disorder was aggravated by any service-connected disorder or treatment therefor, including as a result of any medications taken to treat another disorder. See June 2019 Board Decision. The Veteran was afforded a VA examination in March 2020. The examiner provided opinions for direct service connection, exposure to Agent Orange and secondary service connection. The examiner concluded that the Veteran’s tremor disorder was less likely than not incurred in or caused by the claimed in-service injury, event or illness. He reasoned that the Veteran’s essential tremor diagnosis was present since 1970 and has slowly progressed, which is typical of the disorder. However, he found it did not appear that the tremor disorder began during the Veteran’s military service. He also noted that the Veteran did not have Parkinson’s disease, secondary parkinsonism, or Parkinson’s plus syndrome. Regarding exposure to herbicide agents, the examiner concluded that the Veteran’s essential tremor disorder was not caused by presumed exposure to herbicide agents. He reasoned that there was no known recognized cause of essential tremor disorder other than possibly genetics. The Veteran noted he does not have a family history of tremors. Regarding secondary service connection, the examiner concluded the Veteran’s essential tremor disorder was not caused or aggravated by any service-connected disorder. See March 2020 VA examination. The Board finds that the examiner’s rationale regarding service connection is conclusory, unclear, and appears to be based on an inaccurate factual predicate. Specifically, the examiner concluded that there was no known recognized cause of essential tremor disorder other than genetics. The examiner reasoned that the Veteran’s essential tremors were most likely related to genetics but identified no evidence to support his claim. However, the Veteran reported that he did not have family history for essential tremors. This opinion lacks sound reasoning and appears to be based on an inaccurate predicate; therefore, the examination lacks probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the probative value of a medical opinion is derived from its factually accurate, fully articulated, and sound reasoning for the conclusion); Reonal v. Brown, 5 Vet. App. 458 (1993) (noting that a medical opinion based on an inaccurate factual predicate lacks probative value). Further, the examiner neither provided specific bases for the general conclusions, nor addressed whether Agent Orange exposure caused or aggravated the Veteran’s essential tremor disorder. A review of the evidence of record shows that VA has conceded the Veteran was exposed to Agent Orange while serving in Korea. See March 2016 Statement of the Case. Moreover, the March 2020 VA examiner’s opinions did not adequately consider the matters of secondary causation and aggravation. Specifically, the examiner did not provide any rationale to support his causation or aggravation opinion. El-Amin v. Shinseki, 26 Vet. App. 136 (2013). In sum, the Board finds that an additional examination is necessary in order to fully consider the evidence of record. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain an opinion, it must ensure that the examination or opinion is adequate).  The matter is REMANDED for the following action: Return the file back to the March 2020 examiner (or another appropriate examiner if the March 2020 examiner is unavailable) to ascertain the nature and etiology of the Veteran’s essential tremor disorder. Any indicated evaluations, studies, and tests deemed necessary should be accomplished. After eliciting a history of the Veteran’s disability, the examiner should offer comments, an opinion and a supporting rationale for the following (a.) Is it at least as likely as not (i.e., at least a 50 percent probability) that the Veteran’s essential tremor disorder was caused by an in-service event, disease, disorder, or injury; including as a result of exposure to Agent Orange? The examiner must address the Veteran’s contention that he was exposure to Agent Orange and began experiencing tremors in his hands shortly after discharge. See December 2014 Statement in Support of Claim. Additionally, the examiner should note the VA has previously conceded the Veteran’s exposure to Agent Orange while serving in Korea. See March 2016 Statement of the Case. The examiner is reminded that the fact that essential tremors is not entitled to presumptive service connection based on herbicide exposure is not a sufficient basis for a negative nexus opinion. (b.) Is it at least as likely as not (i.e., at least a 50 percent probability) that the Veteran’s essential tremor disorder was either (1) caused by or (2) aggravated by any of his service-connected disabilities, to include related medication use? In responding to (b.), the examiner should note the Veteran’s service-connected disabilities include degenerative disease of the thoracic spine with thoracic spondylosis to include mild degenerative arthritis and mild degenerative disease L3-4 with radicular symptoms but without radiculopathy and a sleep disorder/ insomnia. [CONTINUED ON NEXT PAGE] A complete medical rationale for all opinions expressed must be provided, to include discussing the specific facts of this Veteran’s case. If an opinion cannot be provided without resorting to speculation, the examiner should provide complete explanations of why this is so. In so doing, the examiner is requested to explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or the limits of current medical knowledge have been exhausted in providing an answer to that particular question. Kate E. Kovarovic Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Emily A. Kotroco 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.