Citation Nr: 21022356 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 15-33 414 DATE: April 15, 2021 REMANDED Entitlement to service connection for a left hip disability is remanded. Entitlement to service connection for a bilateral upper extremity neurological impairment is remanded. REASONS FOR REMAND The Veteran had active duty military service from August 1974 to July 1979 and from August 1990 to November 1995, including service in Southwest Asia. In August 2019, the Board remanded the claim for the RO to readjudicate the appeal in a supplemental statement of the case after VA generated evidence was associated with the claims file subsequent to the September 2015 statement of the case. The case has since returned to the Board for further appellate consideration. On review, the Board finds that a remand is necessary to provide the Veteran with adequate VA examinations in connection with his claims. Left Hip Disability The Veteran seeks service connection for a left hip disability, which he attributes to an injury sustained during a fall in service. The evidence establishes that the Veteran sustained such an injury and landed on a toolbox which resulted in injuries to his left hip, buttock, and low back. See service treatment records dated on October 16, 2008. The evidence also shows that the Veteran has been treated for left hip pain on multiple occasions. In April 2015, the Veteran underwent a VA examination which found no current diagnosis of a left thigh or hip disability. However, despite abnormal limitation of motion, the examiner provided no explanation as to why a current diagnosis was not rendered. Furthermore, no imagine studies of the hip or thigh have been performed. Accordingly, the Board assigns little to no probative value to this examination report. Bilateral Upper Extremity Peripheral Neuropathy The Veteran seeks service connection for peripheral neuropathy affecting both his upper extremities. Notably, he has been found to have had exposure to herbicidal agents such as Agent Orange and he has attributed his symptoms to this exposure. In addition, the Veteran is service connected for both diabetes mellitus and degenerative joint disease of the cervical spine, both of which can result in neurological symptoms. All of these potential etiologies must be considered in adjudicating this claim. A neurological consultation in October 2012 noted the Veteran’s exposure to herbicides and his cervical spine disability as possible causes of his peripheral neuropathy. See CAPRI, 06/24/2013. A November 2012 treatment record showed a diagnosis of mild asymmetrical global sensory polyneuropathy of the upper and lower extremities. See CAPRI, 09/21/2015. The Veteran underwent an April 2015 VA examinations. One examination was focused on polyneuropathy and found no evidence of neuropathy in the upper extremities. The second focused on the cervical spine and found no evidence of neuropathy or radiculopathy related to the cervical spine. A medical opinion from October 2015 noted that the Veteran had a history of paresthesias (numbness and tingling) of his hands and feet going back to 1980 and had been diagnosed with diabetes in 2013. The examiner opined that the Veteran’s bilateral upper extremity peripheral neuropathy was less likely than not the result of his diabetes mellitus, based on the fact that it manifested prior to the diagnosis of diabetes in 2013. The examiner found that it had been aggravated by his diabetes but was unable to provide a baseline which would allow for secondary service connection to be granted because the diabetic and polyneuropathy symptoms were so enmeshed. The Veteran’s upper extremity neuropathy has been denied as a presumptive claim because it was not manifested to a compensable degree within one year of his last exposure as required by 38 U.S.C. § 1116. The Veteran has asserted that he did not understand what the tingling in his hands was when first manifested and did not associate it with the term neuropathy or his exposure to herbicidal agents. Based on the multiple possible causes for the Veteran’s upper extremities of neuropathy, the Board finds that the medical opinions of record are not adequate for adjudicative purposes. Specifically, the examiner does not address the questions of radiculopathy from the service-connected cervical spine disability and any significant distinguishing features between neuropathy and radiculopathy. In addition, the Veteran’s history regarding the manifestation of his symptoms with respect to his hands and arms must be clarified to determine if the requirements for service connection under 38 U.S.C. § 1116 have been met. The matters are REMANDED for the following action: 1. Ensure that all outstanding VA treatment records are associated with the claims file. 2. Thereafter, provide the Veteran with a VA examination to determine the nature and etiology of the claimed left hip disability. The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials. All indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a review of the record and examination of the Veteran, the examiner is asked to respond to the following: (a) Identify all currently diagnosed left hip disabilities. Please ensure all necessary studies, such as x-rays are conducted. (b) If a disability is not diagnosed, address whether the Veteran’s competent reports of left hip pain and the limited range of motion during the 2015 VA examination/current examination result in functional impairment of earning capacity. (c) For each currently diagnosed left hip disability and/or symptoms resulting in functional impairment of earning capacity, provide an opinion as to whether it, at least as likely as not (50 percent or greater probability), had its onset during service or is otherwise etiologically related to it. (d) For each currently diagnosed left hip disability and/or symptoms resulting in functional impairment of earning capacity, provide an opinion as to whether it, at least as likely as not (50 percent or greater probability), was caused or aggravated by a service-connected disability. A complete rationale should be provided for all opinions on direct, causation, AND aggravation. 3. Thereafter, provide the Veteran with a VA examination to determine the nature and etiology of the claimed bilateral upper extremity neurological impairment. The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials. All indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a review of the claims file and examination of the Veteran, the examiner is asked to respond to the following: (a) Identify all currently diagnosed neurological impairments of the right and/or left upper extremities. (b) Elicit from the Veteran the history of all signs and symptoms associated with the claimed neurological impairment during service and since separation from service. (c) For each currently diagnosed neurological impairment, provide an opinion as to whether it, at least as likely as not (50 percent or greater probability), had its onset during service or is otherwise etiologically related to it, to include conceded exposure to herbicide agents. In doing so, please address the Veteran’s competent lay assertions and indicate whether the reported symptoms were early manifestations of peripheral neuropathy. (d) For each currently diagnosed neurological impairment, provide an opinion as to whether it, at least as likely as not (50 percent or greater probability) was caused or aggravated by a service-connected disability, to include a cervical spine disability and/or diabetes mellitus. A complete rationale should be provided for all opinions on direct, causation, AND aggravation. (Continued on the next page)   4. Thereafter, readjudicate the remanded claims. A. Yaffe Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Cheryl E. Handy 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.