Citation Nr: 21029080 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 13-00 505 DATE: May 12, 2021 REMANDED Entitlement to service connection for aphasia is remanded. Entitlement to service connection for memory loss is remanded. Entitlement to service connection for a left arm disability is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1988 to September 1989 in the United States Air Force, and April 2003 to June 2003 and September 2003 to December 2003 in the United States Army. The claim was most recently before the Board in July 2020. There has not been substantial compliance with the remand directives and the claims must be remanded again. Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for aphasia is remanded. 2. Entitlement to service connection for memory loss is remanded. Unfortunately, there has not been substantial compliance with the Board's previous remand directives for these issues and another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). The prior remand included directives to obtain the appropriate VA examinations and medical opinions for the aphasia and memory loss claims. The text of the remand specifically stated that the Veteran had not undergone a VA "Gulf War" examination and it was necessary to provide one. With respect to the opinion requested, if symptoms of aphasia and memory loss were not found to be attributable to known diagnoses the Board directed that the examiner opine whether such symptomatology represents an objective indication of a chronic disability resulting from undiagnosed illness related to Persian Gulf War service, or a medically unexplained chronic multi-symptom illness defined by a cluster of signs or symptoms. No Gulf War examination was provided, but in February 2021 a VA examiner opined that the Veteran does not have a diagnosis of aphasia or any memory-related diagnosis, but did not provide an opinion on whether these symptoms represent an undiagnosed illness. Additionally, the Board finds that an actual Gulf War examination is necessary in this case as neither condition has been adequately addressed in any of the various VA examinations the Veteran has undergone to date. Therefore, further remand is necessary. 3. Entitlement to service connection for a left arm disability is remanded. The claim must be remanded again because the February 2021 VA opinion is inadequate. No VA examiner has opined whether the Veteran's diagnosed left wrist condition is caused or aggravated by his service-connected disabilities. The February 2021 VA examination noted left-elbow flare-ups, but no specific diagnosis was offered. The examiner appeared to concede that they were unable to provide a diagnosis that would contemplate the extent of the Veteran's left arm symptoms. However, the opinion also acknowledges the existence of a possible left wrist condition without further explanation or opinion. The matters are REMANDED for the following action: 1. Schedule the Veteran for an appropriate examination to determine the nature and etiology of his aphasia and memory loss. The examiner must review the entire claims file, including a copy of this remand. The examiner should conduct all appropriate diagnostic testing. The examiner should then record all noted signs and reported symptoms, document all clinical findings, and provide a diagnosis if possible. The examiner is asked to provide responses to the following: A) Identify the Veteran's objective indications of a disability. "Objective indications" of a qualifying chronic disability include both objective evidence perceptible to an examining physician and other non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Non-medical indicators include evidence such as time lost form work, the veteran having sought treatment for his symptoms, and change in the veteran's appearance, physical abilities, and mental or emotional attitude. 60 Fed. Reg. 6661, 6663 (Feb. 3, 1995). B) By history, physical examination, or laboratory testing, can the Veteran's objective indications of aphasia and memory loss be attributed to a known clinical diagnosis? If the signs and symptoms are not characteristic of a known clinical diagnosis, the examiner should so indicate. There is no requirement that the examiner provide a diagnosis of undiagnosed illness. C) If the Veteran's objective indications cannot be attributed to a known clinical diagnosis, is there affirmative evidence that the undiagnosed illness is not incurred during active service during the Persian Gulf War or that it was caused by a supervening condition or event that occurred since the Veteran's departure from service during the Persian Gulf War? The examiner should note that a positive response to this question requires affirmative evidence. The mere absence of evidence is not sufficient. D) If the Veteran's objective indications of aphasia and memory loss can be attributed to a known clinical diagnosis, is the etiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood? This determination as to each must be based on the Veteran's specific case and cannot be based on the etiology of the disease or disability population as a whole. E) If the Veteran's objective indications of aphasia and memory loss can be attributed to a known clinical diagnosis, is the pathophysiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood? This determination as to each must be based on the Veteran's specific case and cannot be based on the pathophysiology of the disease or disability population as a whole. F) If both the etiology and pathophysiology are partially understood or fully understood, then is it at least as likely as not (a 50 percent or greater probability) that the Veteran's diagnosed condition(s) was incurred in, or is otherwise related to, his active service? A complete rationale must be provided for all opinions expressed. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any left arm or wrist disability. Copies of all pertinent records must be made available to the examiner for review. Based on an examination, review of the record, and any tests or studies deemed necessary the examiner should provide opinions as to the following: (a) Identify all diagnosed left arm or wrist disabilities since 2008. (b) For each diagnosed left arm or wrist disability, is it at least as likely as not related to an in-service injury, event, or disease? (c) If no specific left arm or wrist disability is diagnosed, the examiner must consider whether any pain results in functional impairment of earning capacity. For any identified functional impairment of the left arm or wrist, the examiner must opinion whether it is at least as likely as not related to an in-service injury event, or disease. (d) Additionally, obtain an addendum opinion regarding whether any diagnoseable left arm or wrist disability, or any disability that results in identifiable functional impairment, is proximately due or aggravated by service-connected disability. The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. If an opinion cannot be provided, the examiner should indicate why. 3. Confirm that the VA medical opinion provided comports with this remand, specifically that the standard for the secondary aggravation opinion is any increase in disability, not the standard of beyond the natural progression as noted on the examination form itself. If not, get an addendum. M.E. Larkin Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P.S. McLeod 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.