Citation Nr: 21027254 Decision Date: 05/05/21 Archive Date: 05/05/21 DOCKET NO. 16-57 028 DATE: May 5, 2021 REMANDED 1. Service connection for loss of sensation of the left upper extremity is remanded. 2. Service connection for loss of sensation of the left lower extremity is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1996 to March 1996. This matter originally came before the Board of Veterans' Appeals (Board) from a December 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). This matter has previously been remanded by the Board for further development, most recently in November 2020. This matter is again before the Board and has been advanced on the docket pursuant to 38 C.F.R. § 20.902(c). The Board notes that some of the private treatment records are very difficult to read due to the handwriting. The Veteran is invited, if desired, to obtain typed copies of his private treatment records from the relevant physicians and submit them to VA. The Board also notes that the issue of service connection for loss of sensation of the right side of the body is again REFERRED to the RO for adjudication. See May 2014 NOD. Service connection for loss of sensation of the left upper extremity and service connection for loss of sensation of the left lower extremity are remanded. The Veteran believes that service connection for loss of sensation of the left upper extremity and left lower extremity is warranted. See March 2021 Appellate Brief. A November 2020 Board decision remanded the matter, in part, for a new VA examination. See November 2020 BVA Decision. The examination took place in December 2020. See December 2020 C&P Exam. The examination found, in part, that the Veteran's current disabilities were not related to service because objective medical testing during service did not show peripheral neuropathy or the Veteran's other current disabilities, the Veteran was diagnosed with a conversion disorder during service, and because the Veteran developed peripheral neuropathy many years following service. The Board finds the December 2020 examination inadequate because it did not consider/was unable to consider all the relevant evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Specifically, among other evidence, the examination did not consider/was unable to consider a medical record from 2014 showing that the Veteran had never been diagnosed with a mental disorder, did not have a diagnosis of a conversion disorder, and that the reported symptoms and observations during service were not compatible with a diagnosis of a conversion disorder. See January 2014 CAPRI. The examination also did not consider/was unable to consider medical records showing that the testing done on the Veteran during service were last performed around 18 days following the onset of the Veteran's symptoms. However, it would take at least 21 days following the onset of the Veteran's type of neuropathy for the testing to show the neuropathy damage. See May 2017 Statement in Support of Claim. Finally, the examination did not consider/was unable to consider the Veteran's reports of continuity of symptomatology during and since service. See March 2021 Appellate Brief; May 2017 Statement in Support of Claim. Another examination previously took place in January 2014. It found that the Veteran never had a mental health diagnosis, the Veteran did not have a diagnosis of a conversion disorder, and that the reported symptoms and observations of the Veteran's left extremities during service were not compatible with a diagnosis of a conversion disorder. See January 2014 CAPRI. The Board also finds the January 2014 examination inadequate because it did not provide an adequate rationale for why the reported symptoms and observations of the Veteran's left extremities during service were not compatible with a diagnosis of a conversion disorder. See Nieves-Rodriguez, 22 Vet. App. at 295. This is especially true when a previous examination specifically stated that a conversion disorder causes suffering from neurological symptoms such as numbness and paralysis without an organic cause. See December 2013 CAPRI. This seems to line up with the Veteran's numbness and paralysis during service. See March 1996 STR Medical; July 2013 STR - Medical. The examination is also inadequate because it was based on inaccurate facts, namely, that the Veteran never had a mental health diagnosis even though he was diagnosed with a conversion disorder during service. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); March 1996 STR Medical; July 2013 STR - Medical. The Board notes that it previously found the December 2013 and December 2019 examinations inadequate. See August 2018 BVA Decision; November 2020 BVA Decision. Therefore, a remand for a new examination is needed. The matter is REMANDED for the following action: 1. Provide the Veteran with an opportunity to identify any relevant outstanding private and/or VA treatment records, including but not limited to, hospital records from 2002 and 2012 in Ponce and Damas respectively. See December 2019 C&P Exam. After obtaining any necessary authorizations from the Veteran, make all reasonable attempts to obtain the outstanding records in accordance with 38 C.F.R. § 3.159. 2. Update VA and private treatment records. VA treatment records appear current up to December 2020. 3. Schedule one or more appropriate VA examinations for the Veteran's left upper extremity and left lower extremity disabilities. This should include physical and mental health examinations. The need for an in-person examination of the Veteran is left to the discretion of the examiner. Following a review of the claims file and a copy of this Remand, the reviewing examiner is requested to furnish an opinion with respect to the following: (A) Identify all left upper extremity and left lower extremity related disabilities, physical and mental, existing at any point during the pendency of the appeal (i.e. since July 2013), even if they are currently asymptomatic or have resolved during the pendency of the appeal. (B) For each identified disability, is it at least as likely as not (a 50 percent or greater probability) that the disability had its onset during service, manifested within one year following service, or is otherwise related to service? In addition to the other relevant evidence of record, the examiner is asked to consider the following information with a caution that this list is not a substitute for a review of the record: (1) A medical opinion from a neurologist which states that the Veteran's left upper extremity and left lower extremity problems are related to service. Further information is provided, including specific diagnoses. See March 2021 Medical Treatment Record. (2) The Veteran's report of continuity of symptomatology during and since service. See March 2021 Appellate Brief. (3) A medical record from 2020 showing diagnoses of left C6/C7 radiculopathy, bilateral L5-S1 radiculopathy, bilateral carpal tunnel syndrome, and bilateral lower extremity demyelinating neuropathy, all confirmed by NCV/EMG in 2014. The Veteran reported numbness and paresthesias of the extremities, which felt like a shooting pain. He had been seen by many doctors. See December 2020 C&P Exam. (4) The Veteran's report that the left upper extremity and left lower extremity problems were due to a series of injections during service, which he immediately complained about. See October 2020 Appellate Brief. (5) A medical record from 2019 showing the Veteran's report of the onset and treatment of the left upper extremity and left lower extremity problems during service. Since that time, the problems had continued. He went to the hospital for the problems in 2002 and 2012. Muscle strength and reflex tests showed problems on the left side. The examiner believed that a conversion disorder may have played a role. Further information is provided. See December 2019 C&P Exam. (6) Medical records showing the Veteran's history of an adverse reaction to the vaccines during service, which caused extremity problems. The last NCV/EMG tests during service were conducted about 18 days following the onset of symptoms. However, it would take at least 21 days following the onset of symptoms for the tests to show demyelinating neuropathy problems. Further information is provided. See May 2017 Statement in Support of Claim. (7) Medical records from 2016 showing a positive depression screening, polyneuropathy, and the Veteran's report of polyneuropathy and a history of carpal tunnel syndrome. Further information is provided. See April 2017 CAPRI. (8) Medical records from 2016 showing diagnoses of lumbar radiculopathy, cervical radiculopathy, and polyneuropathy. See April 2017 Medical Treatment Record. (9) The Veteran's report of the onset and treatment of the left upper extremity and left lower extremity problems during service and how the problems had worsened since. He had upper and lower extremity neuropathy, carpal tunnel syndrome, and more. See May 2014 NOD. (10) Medical records from 2014 showing test results which were compatible with demyelinating polyneuropathy, bilateral L5 and S1 radiculopathies, and C6 and C7 radiculopathies. The Veteran had a history of left upper extremity and left lower extremity problems during service following vaccination. He continued with the same complaints ever since, except there had been a progression of the problems. Further information is provided. See May 2014 Medical Treatment Record. (11) The Veteran's report that he still suffered from the residuals of the problems that started during service. See January 2014 NOD. (12) A medical record from 2014 showing that the Veteran had never been diagnosed with a mental disorder, that he did not have a diagnosis of a conversion disorder, and that the reported symptoms and observations during service were not compatible with a diagnosis of a conversion disorder. The Veteran did not have a history of mental health problems before service. Further information is provided. See January 2014 CAPRI. (13) A medical record from 2013 showing the Veteran's report that the left upper extremity and left lower extremity problems began after he was vaccinated during service and that he complained about the problems within 24 hours. The examination talks about the treatment and diagnoses given during service. The examination also shows that a conversion disorder causes suffering from neurological symptoms such as numbness and paralysis without a definable organic cause. Further information is provided. See December 2013 CAPRI. (14) Service records showing the onset and treatment for left upper extremity and left lower extremity problems following vaccination. The Veteran had never had similar symptoms before. Multiple diagnoses and assessments, including but not limited to, neuropraxia, a conversion disorder, hemiparesis and hemianesthesia (most likely functional), brachial plexitis, polyneuritis, and Parsonage-Turner Syndrome were listed. Testing showed problems on the left side. The Veteran had a positive TB test. See July 2013 STR Medical; March 1996 STR Medical. (15) All other relevant lay and medical evidence. A complete rationale for all opinions offered should be provided. Address the Veteran's documented history and assertions. Address the Veteran's reports of continuity of symptomatology during and since service. Address the positive nexus opinion. Address the medical record which stated that it would have taken at least 21 days following the onset of symptoms for the NCV/EMG tests in service to show demyelinating neuropathy problems and that the final NCV/EMG tests during service were performed around 18 days after the onset of symptoms. Address the medical record which stated that the Veteran never had a diagnosis of a conversion disorder or any other mental health disorder and the medical record showing what a conversion disorder does. All necessary tests and studies should be conducted. If the examiner cannot provide an opinion without resorting to mere speculation, the examiner should provide an explanation stating why. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is due to the limits of the medical community's knowledge or due to the limits of the examiner's medical knowledge. The Veteran is competent to attest to factual matters of which the Veteran has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. 4. Readjudicate the issues on appeal. MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Dougan, 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.