Citation Nr: 21026456 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 13-15 735 DATE: May 3, 2021 REMANDED Entitlement to service connection for idiopathic paresthesias, bilateral upper extremities (UE) to include as due to service-connected DM2 is remanded. Entitlement to service connection for idiopathic paresthesias, right lower extremity (RLE), to include as due to service-connected DM2 is remanded. Entitlement to service connection for idiopathic paresthesias, left lower extremity (LLE), to include as due to service-connected type II diabetes mellitus (DM2) is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1969 to May 1971 with service in Vietnam. These matters originally came before the Board of Veterans' Appeals (Board) on appeal from a February 2009 decision of the Department of Veterans Affairs (VA) Regional Office (RO) which in pertinent part denied service connection for idiopathic bilateral upper extremity paresthesias (claimed as pain and tingling in fingers), and idiopathic bilateral lower extremity paresthesias (claimed as pain and tingling in feet). The Veteran and his spouse testified before the undersigned Veterans Law Judge in a December 2015 videoconference hearing. A transcript from the hearing was associated with the claims file and reviewed. Following multiple remands for further development in February 2016 and July 2017, the Board issued a decision in March 2019 which denied service connection for idiopathic paresthesias, bilateral UE and idiopathic paresthesias RLE and remanded the issue of service connection for idiopathic paresthesias LLE for additional development. The Veteran appealed the March 2019 Board denial of service connection for idiopathic paresthesias, bilateral UE and idiopathic paresthesias RLE to the Court of Appeals for Veterans Claims (CAVC) which in an October 2019 decision, granted a joint motion for partial remand (JMR). Following this the Board remanded this matter for development in accordance with the JMR in April 2020. While this post JMR remand was pending, development was undertaken for the separate appeal stream issue of service connection for idiopathic paresthesias LLE following another remand in November 2020 and then was recertified and returned to the Board. The appeal streams have been merged for the Board to address together. 1. Entitlement to service connection for idiopathic paresthesias, bilateral UEs and RLE is remanded. The Board finds that development that had been ordered by the Board's remand in April 2020 has yet to be accomplished. In this prior remand, which was in response to the CAVC's JMR, the Board directed that the RO obtain a VA examination by an appropriate clinician to determine if it is at least as likely as not that the currently diagnosed neurologic disabilities in the bilateral UEs and in the RLE had their onset in or are otherwise related to active service. No such examination was scheduled following the April 2020 remand, although a VA addendum opinion was obtained in December 2020 to address the limited issue of service connection for idiopathic paresthesias of the LLE. This addendum opinion only discussed the etiology of the LLE paresthesias, and does not satisfy the development requested regarding the etiologies of the neurologic disabilities in the bilateral UEs and in the RLE. The RO failed to substantially comply with the Board's April 2020 remand directives; as such, an additional remand is necessary before the Board can adjudicate the issues on appeal. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (the Veteran has the right to compliance with remand orders by the Board). The Board is cognizant that prior to the April 2020 remand, a January 2020 VA DBQ (received in February 2020) was completed in order to address the nature and etiology of idiopathic paresthesias of the LLE, with the neurological examination including the BUE and RLE as well as the LLE. No significant neurological pathologies were disclosed regarding the BUE and RLE. However, the examination itself was not fully complete as there was no evidence that electrodiagnostic testing was done, nor is there evidence such testing was ever done in the available records. Further the examiner declined to complete the diabetic sensory DBQ on the basis that the claimed neuropathy is not due to diabetes. No further rationale was given for this conclusion that the neuropathy was not due to diabetes in this DBQ. Accordingly, the Board finds these matters should be remanded again to obtain an examination to address whether the Veteran has any neurological disorders of the bilateral upper extremities and/or right lower extremity either related to service on a direct basis or secondary to his service connected Type II diabetes. 2. Entitlement to service connection for idiopathic paresthesias LLE is remanded. The Board finds that development of this matter remains inadequate and it is again necessary to remand these issues. In the most recent remand of November 2020, the Board remanded this matter to specifically obtain an addendum opinion accompanied by adequate rationale to address the etiology of the claimed disorder idiopathic paresthesias LLE. The November 2020 remand pointed out that an addendum VA opinion of January 2020 (received in February 2020) continued to provide inadequate rationale. Unfortunately, the most recent VA addendum opinion obtained from the VA examiner in December 2020 who provided the January 2020 opinion continues to provide inadequate rationale. Although the examiner had stated that in the January 2020 opinion that the Veteran's neuropathy did not have characteristics consistent with a diabetic neuropathy, the examiner when addressing the question of aggravation by diabetes then stated that she was unable to determine the level of severity, stating that symptoms were subjective. This is contrary to the objective findings in the January 2020 DBQ, which did find objective findings of decreased muscle strength of 4/5 and decreased sensory findings in the LLE, with findings moderate incomplete paralysis left Posterior tibial nerve & Internal popliteal (tibial) nerve. The December 2020 addendum did not address this contradictory conclusion of subjective symptoms only, and further when discussing the time of onset of diabetes, gave the wrong year of 2019, when the medical evidence shows that diabetes was diagnosed in October 2018. An adequate medical opinion must contain not only clear conclusions, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Furthermore, as pointed out above, the January 2020 examination itself was not fully complete as there was no evidence that electrodiagnostic testing was done, and the examiner declined to complete the diabetic sensory DBQ. Accordingly, the Board finds these matters should be remanded again to obtain an examination to address whether the Veteran has any neurological disorders of the left lower extremity either related to service on a direct basis or secondary to his service connected Type II diabetes. The matters are REMANDED for the following action: Schedule the Veteran for a VA neurological disorder examination by an appropriate clinician, including a diabetic evaluation for neurological manifestations of diabetes. The examination is to address the nature and etiology of any neurological disorders of the bilateral upper and bilateral lower extremities. The examiner must review the claims file. All appropriate testing should be conducted including electrodiagnostic testing if appropriate. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is at least as likely as not (at least a 50 percent probability) that any currently diagnosed neurologic disabilities in the right and left upper extremities and/or in the right and left lower extremities had their onset in or are otherwise related to active service including due to in-service exposure to herbicide agents? The examiner is advised that a negative opinion regarding herbicide exposure cannot be based solely on the fact that the disability is not on the list of diseases that are presumptively associated with exposure to herbicide agents. For any neurological disorder of the right and/or left upper and/or lower extremities found not to be directly related to service, the examiner should also opine whether it is at least as likely as not that the Veteran's neurological symptoms impacting the left and/or right upper and/or lower extremities are proximately due to his service-connected Type 2 diabetes mellitus. If the answer is negative, then the examiner should opine whether it is at least as likely as not that the service-connected diabetes mellitus worsens any neurological symptoms (including paresthesias or other neurological symptoms) impacting his right and/or left upper and/or extremities. If so, please provide a baseline of aggravation in terms of a percentage. All opinions should be accompanied by adequate rationale. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Eckart 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.