Citation Nr: 21025149 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 11-06 302 DATE: April 27, 2021 REMANDED Entitlement to service connection for peripheral neuropathy of the right upper extremity is remanded. REASONS FOR REMAND The Veteran served on active duty in United States Army from April 1965 to March 1967. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2009 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in August 2016, July 2017, and September 2019. Unfortunately, it is necessary to remand the claim once more. When a case is remanded, a veteran is entitled to substantial compliance with all remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). If the RO does not substantially comply with the Board’s remand instructions, the Board is legally bound to continue remanding until the mistake is corrected. See id. Additionally, VA has a duty to ensure that any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board’s evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). In September 2019, the Board remanded the claim to obtain a VA examiner’s opinion on whether the Veteran’s peripheral neuropathy of the right upper extremity was directly connected to his military service. In November 2019, a VA examiner (specifically, a medical doctor) opined that the Veteran’s peripheral neuropathy was less likely than not caused by his service-connected diabetes mellitus, but did not offer an opinion on whether the condition was directly related to the Veteran’s military service. The RO caught this mistake, and asked the examiner for an addendum opinion regarding direct service connection. In August 2020, the same examiner issued an addendum opinion stating they could not resolve the issue without resort to mere speculation, and that it would be appropriate to refer the case to a neurologist for a specialized opinion. The RO next requested an opinion from a psychologist, who wrote a note in January 2021 that stated only “this is not a question for psychology.” The RO then requested another opinion; in February 2021, a psychiatrist opined that it was less likely than not that the Veteran’s peripheral neuropathy was related to his military service, because: There is no evidence to support the claim that the Veteran’s right upper extremity peripheral neuropathy (1) began during active service, (2) manifested within the applicable presumptive period after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. This opinion is inadequate for two reasons. First, and most importantly, it fails to address whether the Veteran’s peripheral neuropathy is related to his in-service exposure to herbicide agents, as specifically instructed in the September 2019 remand. In fact, the February 2021 opinion does not discuss the etiology of the Veteran’s right upper extremity peripheral neuropathy at all. Manifestation during service (or, for some chronic conditions, within a presumptive period after discharge) is only one of the ways a disability can be directly service connected; entitlement to service connection shall be granted for any disability that is found to be caused by an in-service disease, injury, or event, even if the disability does not develop until years after service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Second, the Board questions the RO’s decision to have a psychiatrist perform the February 2021 examination. Typically, there is no strict requirement that VA examinations be performed by a specialist in a particular area of medicine, so long as the examiner has enough training and expertise to give a competent opinion. See 38 C.F.R. § 3.159(a)(1). However, in this case, a medical doctor told the RO that a neurologist’s opinion was required to resolve the issue—and indeed, the non-neurologist that was consulted offered an inadequate rationale. Even if the RO was unable to find a neurologist to conduct an examination, it is unclear why they would seek an opinion from a psychiatrist, when there is no indication in the record that the claimed condition is psychiatric. The Board also finds that the rationale of the November 2019 opinion, regarding secondary service connection, was inadequate. The November 2019 opinion found that the Veteran’s right upper extremity peripheral neuropathy was less likely than not caused by his diabetes, finding that “onset of these neuropathies occurred prior to onset of diabetes mellitus.” The Veteran was diagnosed with right cubital syndrome and carpal tunnel syndrome in March 2007, while the onset of diabetes mellitus “is assumed to be” October 2009, based on a private treatment note from April 2010 that describes the Veteran’s appointment “as a return visit for hypothyroidism and impaired glucose tolerance on October 8, 2009.” However, the record contains conflicting evidence as to the onset of the Veteran’s diabetes, and it is not clear why the examiner settled on this treatment note as the definitive evidence of when the Veteran’s diabetes began. For example, the examiner did not address a September 2009 letter from one of the Veteran’s treating physicians, which stated the Veteran had “been a borderline diabetic” since at least January 2006, over a year before the Veteran’s right arm neuropathy was diagnosed. A VA examination conducted in September 2017 had the same deficiency. The matter is REMANDED for the following actions: 1. Obtain an opinion from an appropriate clinician— specifically a neurologist —regarding the etiology of the Veteran’s peripheral neuropathy of the right upper extremity. It is in the examiner’s discretion whether a new in-person or telehealth examination should be scheduled. The Veteran’s entire claims file (including a copy of this remand) must be made available to the examiner for review, and the examiner must certify in the addendum opinion report that the claims file has been reviewed. After reviewing the entire claims file, the examiner should answer the following: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s peripheral neuropathy of the right upper extremity is related to an in-service injury, disease, or event? Specifically address the Veteran’s conceded exposure to herbicide agents. (b) Is it at least as likely as not that the Veteran’s peripheral neuropathy of the right upper extremity had its onset during service, or within a year after separation? (c) Is it at least as likely as not that the Veteran’s peripheral neuropathy of the right upper extremity was caused or aggravated by the Veteran’s service-connected diabetes mellitus? Specifically address the September 2009 letter, which indicates the Veteran showed signs of “borderline” diabetes since at least January 2006. (d) If the Veteran’s peripheral neuropathy of the right upper extremity is not related to his military service or a service-connected condition, what is its likely etiology? The examiner must provide a complete rationale for all opinions, supported by evidence and citing any records or medical literature relied upon. If any of the above requested opinions cannot be made without resorting to speculation, the examiner must explain why. 2. This case has been Advanced on the Docket. The RO must review the examination reports and opinions to ensure they are adequate and comply with the Board’s specific remand directives herein. If an opinion is deficient in any manner, the RO must undertake immediate corrective action before returning the case to the Board. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Shermila Sundquist 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.