Citation Nr: 21028650 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 16-35 438 DATE: May 11, 2021 REMANDED Entitlement to service connection for right lower extremity (RLE) neurological disability, claimed as peripheral neuropathy, is remanded. Entitlement to service connection for a respiratory disability, claimed as chronic obstructive pulmonary disease (COPD), is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) prior to July 19, 2016 is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1972 to December 1973, with additional service in the Air Force Reserves and Air National Guard. These matters come before the Board of Veterans' Appeals (Board) on appeal from a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). Although the Veteran requested a hearing with the Board, he has since expressed to VA in writing the intention to withdrawal the requested Board hearing. See Statement in Support of Claim (October 2016). Since the withdrawal request was received prior to the scheduled hearing date, the Board finds that the hearing request has been withdrawn. 38 C.F.R. § 20.704(e). An October 2019 Board decision remanded the claims to obtain the Veteran's Air Force Reserve and West Virginia Air National Guard service treatment records. The Board finds that more development is necessary prior to final adjudication of the claims on appeal. The Veteran contends that he was exposed to lead and asbestos during his service as a plumbing specialist. See NOD (September 2015). The Veteran also contends that he has RLE neuropathy that is secondary to his toe amputations. See Form 9 (July 2016). The Veteran submitted online literature indicating that occupational hazards for plumbers include pulmonary edema and neuropathy. As a result, the Veteran's military occupational specialty (MOS) duties assigned to plumbing specialist suggests asbestos exposure during service. Thus, exposure is conceded for purposes of scheduling an examination. Regarding a RLE neurological disability, claimed as peripheral neuropathy, a VA examiner opined that the Veteran "might have a neuropathy however it would not be caused by his toe amputation as... radiating pain occurs from superior to inferior regions of the body not the other way around." See C&P Exam (November 2014). However, that opinion is inconsistent with an online article from the National Institute of Health which indicates that nerve compression and nerve trauma "may cause neuropathic pain." See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1810425/ (last accessed May 3, 2021). Although the examiner indicated that lumbar radiculopathy is likely causing the condition, the examiner provided no analysis or reasoning for finding that the Veteran's RLE complaints are due to his lumbar arthritis but not nerve trauma from a gunshot wound to his toes with resulting toe amputations. Regarding a respiratory disability, claimed as COPD, a VA examiner opined that the Veteran's COPD is caused by smoking and that, based on cited online medical literature, "[a]sbestos exposure is not known to cause COPD." See C&P Exam (November 2014). However, the examiner provided no facts specific to the Veteran, such as how many years, and how many packs per year, the Veteran smoked. Notably, the online medical literature cited by the examiner states that "smoking less than 10 to 15 pack-years of cigarettes is unlikely to result in COPD." See https://www.uptodate.com/contents/chronic-obstructive-pulmonary-disease-definition-clinical-manifestations-diagnosis-and-staging (last accessed May 3, 2021). That online medical literature also states that "important risk factors for COPD, such as exposure to fumes or organic or inorganic dusts... help to explain the 20 percent of patients with COPD (defined by lung function alone) and the 20 percent of patients who die from COPD who never smoked." Id. Moreover, the examiner provided no analysis or reasoning for finding that smoking was the cause of the Veteran's COPD. It is noted that a medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record. See Stefl v. Nicholson, 21 Vet. App. 102, 124-25. Also, "a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Therefore, to ensure that VA has met its duty to assist, remand is required to obtain adequate medical opinions. 38 C.F.R. § 3.159(c)(4); Barr, supra. Finally, the issue of TDIU is inextricably intertwined with the service connection claims being remanded for additional development as the appeal period goes back to June 2013. Therefore, the Board must defer consideration of that claim at this time. See Harris v. Derwinski, 1 Vet. App. 181 (1991) (two or more issues are inextricably intertwined if one claim could have significant impact on the other). The matters are REMANDED for the following action: 1. The Veteran should be requested to provide the names, addresses and approximate dates of treatment of all medical care providers, VA and non-VA, who have treated him for the disabilities on appeal. After the Veteran has signed the appropriate releases, those records should be obtained and associated with the claims folder. 2. Once the development directed above is complete, obtain a VA medical opinion from an appropriate clinician to determine the nature and etiology of the Veteran's RLE neurological disability, to include peripheral neuropathy. After reviewing the claims file, to include a copy of this remand, the examiner should opine for each diagnosed neurological disability, to include peripheral neuropathy, as to whether it is at least as likely as not (a 50 percent probability or greater) that the condition is etiologically related to service, to include any exposure to lead, asbestos, and/or environmental contaminates while serving as plumbing specialist, to include while stationed at Plattsburgh Air Force Base. The opinion should, among other things, include a discussion of the Veteran's documented history and assertions, as well as the evidence discussed in this remand. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). 3. Once the development directed above is complete, obtain a VA medical opinion from an appropriate clinician to determine the nature and etiology of the Veteran's respiratory disability, to include COPD. After reviewing the claims file, to include a copy of this remand, the examiner should opine for each diagnosed respiratory disability, to include COPD, as to whether it is at least as likely as not (a 50 percent probability or greater) that the condition is etiologically related to service, to include any exposure to lead, asbestos, and/or environmental contaminates while serving as plumbing specialist, to include while stationed at Plattsburgh Air Force Base. The opinion should, among other things, include a discussion of the Veteran's documented history and assertions, as well as the evidence discussed in this remand. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). 4. Ensure that the VA medical opinions obtained include a complete rationale for the conclusions reached. The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, the examiner must 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), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). (Continued on the next page) 5. Thereafter, readjudicate the issues on appeal. If any benefit sought on appeal remains denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. James A. DeFrank Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Thaddaeus J. Cox, 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.