Citation Nr: 21025560 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 20-25 512A DATE: April 28, 2021 REMANDED Entitlement to service connection for bilateral upper extremity neuropathy is remanded. Entitlement to service connection for bilateral lower extremity neuropathy is remanded. Entitlement to a compensable rating for bilateral hearing loss (BHL) is remanded. Entitlement to an increased initial rating greater than 10 percent coronary artery disease (CAD) is remanded. Entitlement to an effective date earlier than August 18, 2017 for the award of service connection for CAD status post myocardial infarction (MI) is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1966 to May 1968. He appeals a March 2018 rating decision by the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) denying entitlement to service connection for bilateral upper and lower extremity peripheral neuropathy, entitlement to a compensable rating for BHL and an initial rating greater than 10 percent for CAD. The Veteran also appealed the effective date for service connection for his CAD. Service Connection for Bilateral Upper and Lower Extremity Radiculopathy VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence on file for VA to make a decision on the claim. See McLendon, 20 Vet. App. 79. Here, the Veteran claims his bilateral upper and lower peripheral neuropathy were caused by his exposure to herbicide agents while serving in the Republic of Vietnam. August 2017 VA treatment records reflect the Veteran had a “history of neuropathy” and he alleges having “pains in [his] legs and feet and numbness in [his] fingers and the bottom of [his] feet.” See March 2019 Notice of Disagreement (NOD). Thus, the first McLendon element is met. Presumptive exposure to herbicide agents is available for veterans who served in the Republic of Vietnam between January 9, 1962 and May 7, 1975. See 38 C.F.R. § 3.307(a)(6)(iii). Here, the Veteran’s DD Form 214 and service personnel records reflect he served in the Republic of Vietnam during the presumptive period; thus, exposure to herbicide agents is presumed and the second McLendon element is met. While the Veteran is not competent to medically diagnose or opine on the etiology of his peripheral neuropathy, satisfying the third McLendon element requires only that the evidence ‘indicates’ that there ‘may’ be a nexus between the two and is a low threshold. See McLendon, 20 Vet. App. at 83. Thus, as the Veteran has not yet received a VA examination, a remand is required. BHL The Veteran claims his service-connected BHL is more severe than reflected by his noncompensable rating. Specifically, he states he was awarded a noncompensable rating years ago when he “had severe ringing in [his] ears but could hear without amplification” and now he requires “hearing aids to be able to function at work.” See June 2020 VA Form 9. The Veteran’s last audiology examination was conducted in February 2018 and VA treatment records reflect the Veteran’s hearing has worsened since that examination to the extent he was prescribed and fitted for hearing aids in early 2020. See January 2020 VA treatment records. Thus, a new examination is required. See Snuffer v. Gober, 10 Vet. App. 400, 403-04 (1997). Increased Initial Rating and Earlier Effective Date for service connection for CAD As stated above, the March 2018 rating decision granted service connection for the Veteran’s CAD, effective August 18, 2017 and assigned an initial 10 percent rating. However, the Veteran contends he suffered a myocardial infarction (MI) in June 2017 and is therefore entitled to an earlier effective date for service connection in addition to a total disability rating under Diagnostic Code 7006 for the three months following his claimed MI. See December 2018 NOD. Diagnostic Code 7006 requires evidence of any MI to be “documented by laboratory tests.” See 38 C.F.R. § 4.104, Diagnostic Code 7006. The Veteran provided pertinent medical records from his June 2017 hospitalization which note elevated levels of Troponin I. See June 2017 Rancho Springs Medical Center records. However, the Board is limited in its ability to make its own independent medical determinations and it is unclear from the record if elevated levels of Troponin I constitute laboratory documentation of a myocardial infarction. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). As such a remand is required to obtain a medical opinion on whether laboratory testing shows the Veteran suffered MI in June 2017. Additionally, the Board finds the record appears incomplete. The Veteran provided treatment records from Rancho Springs Medical Center for his heart condition; however, the entire record was not provided. For example, the Veteran’s hospital discharge summary noted numerous pending EKGs and other test results that were not included in his record. See June 2017 Rancho Springs Medical Center. Accordingly, on remand the AOJ should make reasonable efforts to obtain any relevant treatment records from Rancho Springs Medical Center. The matters are REMANDED for the following action: 1. Obtain all relevant private and VA treatment records that have not already been associated with the claims file, including, but not necessarily limited to, the Veteran’s complete treatment records from Rancho Springs Medical Center, including the results from his June 2017 EKGs, Chest CT, and other tests conducted in June 2017. If any identified records are not obtainable, or none exist, the Veteran and his representative should be notified, and the record clearly documented. 2. After the development of #1 above is complete, schedule the Veteran for an examination to determine the nature and etiology of the Veteran’s bilateral upper and lower extremity peripheral neuropathy. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. A complete history should be elicited directly from the Veteran and the opinion should include a notation that this record review took place. After a thorough review of the record to include all in-service and post-service treatment records, the examiner should answer the following: Is it at least as likely as not (a 50 percent probability or more) that the Veteran’s bilateral upper and lower extremity peripheral neuropathy was incurred in or is otherwise related to his conceded exposure to herbicide agents while serving in Vietnam? The VA examiner is directed to consider the Veteran’s contentions within his March 2019 NOD. The examiner should note the Veteran is competent to report his symptoms and history and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran’s reports of symptomatology, a reason for doing so should also be provided. The examiner should not mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. A full and complete rationale for all opinions must be provided, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. After the development of #1 above is complete, arrange for a VA audiology examination reassessing the severity of the Veteran’s service-connected bilateral hearing loss. 4. After the development of #1 above is complete, obtain an opinion from an appropriately qualified clinician to determine the nature and severity of the Veteran’s CAD, status post myocardial infarction. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the reviewing clinician. It is up to the discretion of the reviewing clinician whether a new examination is necessary to provide an adequate opinion. After a thorough review of the record, the reviewing clinician should answer the following: Do the Veteran’s medical records contain laboratory tests documenting that he suffered from myocardial infarction in June 2017, to include the cardiac chemistry results for highly elevated Troponin I? The reviewing clinician is directed to review and discuss the June 2017 Rancho Springs Medical Center records submitted by the Veteran in December 2018 indicating (i) elevated Troponin-I and Acute Coronary Syndrome, and (ii) discharge summary noting “Non-st elevation myocardial infarction.” In rendering these opinions, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran’s reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran’s lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. A full and complete rationale for all opinions must be provided, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. (Continued on the next page)   5. After the above has been completed, readjudicate the claims. If any benefit sought remains denied, provide the Veteran and his representative with a supplemental statement of the case (SSOC), and return the case to the Board. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Bona, Associate 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.