Citation Nr: 21030184 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 12-29 161 DATE: May 18, 2021 REMANDED The issue of service connection for a kidney disorder, to include as due to herbicide exposure and/or claimed as secondary to service-connected posttraumatic stress disorder (PTSD) and/or ischemic heart disease (IHD) is remanded. The issue of service connection for peripheral neuropathy, to include as due to herbicide exposure and/or claimed secondary to a kidney disorder is remanded. The issue of service connection for a bilateral eye disability, to include as due to herbicide exposure and/or secondary to service-connected PTSD and/or IHD is remanded. The issue of service connection for a dental disability is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1966 to March 1969. These matters are before the Board of Veterans' Appeals (Board) on appeal from a June 2010 rating decision issued by the RO. The Veteran has been assigned a combined total (100 percent) disability rating effective from March 2014. In an August 2019 decision, the Board denied the Veteran's claims for service connection for a kidney disorder, peripheral neuropathy, and a dental disability. The claim of service connection for a bilateral eye disability was remanded for further development of the record. Specifically, the Board instructed the RO to obtain an addendum opinion as to the etiology of the claimed bilateral eye disability. The addendum opinion was obtained in November 2019 and the claim was returned for appellate adjudication. The Veteran appealed the decision to deny claims for service for a kidney disorder, peripheral neuropathy, and a dental disability to the United States Court of Appeals for Veterans Claims (Court). In December 2020, the Court granted the parties' Joint Motion for Partial Remand (JMPR) and vacated and remanded the Board's August 2019 decision that denied service connection for the disorders In denying the claim for service connection for a dental disability, the Board concluded that there was substantial compliance with prior remand instructions to obtain outstanding dental treatment records. The parties noted that the Veteran had been determined to be incompetent to handle disbursement of funds and his wife was his appointed VA fiduciary. The parties agreed that remand was required for the Board to address whether the Veteran's wife, acting as a valid fiduciary, properly completed the medical release on his behalf. 1. Entitlement to service connection for a kidney disorder, to include as due to herbicide exposure and/or claimed as secondary to service-connected posttraumatic stress disorder (PTSD) and/or ischemic heart disease (IHD) is remanded. 2. Entitlement to service connection for peripheral neuropathy, to include as due to herbicide exposure and/or claimed secondary to a kidney disorder is remanded. 3. Entitlement to service connection for a bilateral eye disability, to include as due to herbicide exposure and/or secondary to service-connected PTSD and/or IHD is remanded. 4. Entitlement to service connection for a dental disability is remanded. The Board has determined that additional development is necessary, and these matters are REMANDED for the following: 1. BACKGROUND FOR THE RO ADJUDICATOR: The Board summarizes the Court's findings below for the adjudicator's information. KIDNEY DISORDER: The Veteran claims that his kidney disorder was caused by service, to include herbicide exposure. He also claims that his kidney disorder was caused or aggravated by his service-connected PTSD and/or IHD. He also claims that his kidney disorder was caused by syphilis during his period of service. Before the Court, VA and the Veteran agreed that the March 2019 VA examiner did not fully explain the opinion PERIPHERAL NEUROPATHY: The Veteran claims he developed peripheral neuropathy due to herbicide exposure during service or that the symptoms began due to syphilis during service. The March 2019 VA examination reflects that the Veteran had paresthesias related to use of anti-rejection drugs status post renal transplant. The examiner opined, in pertinent part, that this was also likely an etiology of his current peripheral neuropathy symptoms. However, adjudication of the kidney claim may effect adjudication of the peripheral neuropathy claim. The RO must therefore defer adjudication of the peripheral neuropathy claim until development and readjudication of the claim for service connection for a kidney disorder has been completed. DENTAL DISABILITY: The June 2017 rating decision documents that the Veteran was incompetent for purposes of managing VA payments. In February 2018, the Veteran's spouse, his valid fiduciary, signed a General Release for Medical Provider Information to the Department of VA (VA Form 21-4142a) authorizing VA to obtain records from the Veteran's treating dentist. In May 2019, VA notified the Veteran and spouse the authorization was invalid because even though his spouse was his fiduciary, his signature was required. However, considering the December 2020 remand that the Veteran's spouse, acting as his valid fiduciary, properly completed the General Release for Medical Provider Information on his behalf, VA must obtain relevant, identified private records from the Veteran's dentists. BILATERAL EYE DISABILITY: The Veteran claims that his bilateral eye disability was caused or worsened by in-service herbicide exposure and/or caused or worsened by to his service-connected PTSD and/or IHD. The August 2018 Report of VA optometry examination found that the Veteran's bilateral eye disabilities were less likely than not incurred in or caused by service. The examiner explained that the Veteran's eye disabilities began decades after service and were age-related. A May 2019 VA optometry addendum indicates the Veteran's eye disabilities were unrelated to PTSD and IHD and medications prescribed for treatment of the service-connected disabilities. The optometrist also opined that the eye disabilities were unrelated to syphilis and could not be caused by syphilis. However, in the August 2019 decision, the Board determined that these examinations were insufficient because the optometrist offered no rationale for the opinions. The Board remanded the issue for an adequate VA addendum opinion to address questions of nexus and aggravation. A November 2019 VA addendum found the Veteran's bilateral eye disabilities are unrelated to his service-connected PTSD and/or IHD, to include medications prescribed for their treatment because the service-connected disabilities cannot cause the bilateral eye disabilities. However, the addendum is AGAIN insufficient for determining whether service connection may be granted BECAUSE THE OPTOMETRIST DID NOT STATE OR EXPLAIN WHETHER THE CLAIMED EYE DISORDERS WERE WORSENED BY THE SERVICE-CONNECTED PTSD AND/OR IHD. THE REMAND DIRECTIVES FOLLOW. 2. Request that the Veteran or his valid fiduciary (i.e., his spouse) provide the names and addresses of all health care providers who have provided treatment for his claimed dental disability whose records have not been obtained. Advise the Veteran or his valid fiduciary (i.e., his spouse) to sign the appropriate authorization forms. Obtain and associate any outstanding pertinent records with the electronic claims file. A specific request must be made for copies of medical treatment records of Andrew Lange, DMD (Doctor of Dental Medicine) from 2004 to 2015. Do not associate duplicate records with the file. If any identified records are not obtainable (or none exist), the Veteran and his valid fiduciary should be notified, and the record clearly documented. 2. Schedule the Veteran for a VA examination to determine the nature and likely etiology of the claimed kidney disorder. The claims file must be reviewed by the examiner. All indicated tests and studies should be performed and the clinical findings should be reported in detail. The Veteran asserts that his kidney disorder onset due to herbicide exposure incurred during service, or as secondary (i.e., caused or aggravated by) to his service-connected PTSD and/or IHD, or due to syphilis that was contracted during his period of service. A comprehensive clinical history should be obtained, to include a discussion of the Veteran's documented medical history and assertions. After reviewing the entire record, the examiner should provide an opinion WITH SUPPORTING EXPLANATIONS as to the following: (A) Does the Veteran have a current kidney that is the result of injury or disease (i.e., presumed herbicide exposure or syphilis) sustained during his period of service? (B) Was the Veteran's current kidney disorder CAUSED OR AGGRAVATED (worsened) by service-connected PTSD and/or IHD (or medications prescribed for their treatment)? If aggravation of any kidney disorder by service-connected PTSD and/or IHD (or medications prescribed for treatment) is shown, the examiner should objectively quantify, to the extent possible, the degree of aggravation beyond the level of impairment had no aggravation occurred. THE EXAMINER MUST CONSIDER AND EXPLAIN WHETHER THE VETERAN'S ACCOUNT OF THE DEVELOPMENT OF THE DISORDER IS CONSISTENT WITH THE MEDICAL EVIDENCE AND THE EXAMINER'S KNOWLEDGE AND PRACTICE EXPERIENCE, ACCOUNTING FOR FACTS AND CIRCUMSTANCES SPECIFIC TO THE VETERAN. As indicated above, the examiner must review the record in conjunction with rendering the requested opinion; however, his/her attention is drawn to the following: *Service Personnel Records document that the Veteran served in the Republic of Vietnam from January 1968 to March 1969. *An October 1968 service treatment record documents diagnosis of syphilis. *June 2011 Report of VA General Medical examination documents diagnosis of endstage renal disease status post (s/p) renal transplant in 2007 that requires medication. *March 2019 Report of VA kidney conditions examination documents diagnosis of kidney transplant. The examiner noted the Veteran had a history of endstage renal disease (ESRD) due to retroperitoneal fibrosis. The examiner opined that the claimed kidney disorder was less likely than not incurred in or caused by an in-service injury, event, or illness. The examiner explained that the Veteran was diagnosed with a rare renal disease, retroperitoneal fibrosis, in 2006, more than 30 years after his discharge from service. The examiner concluded the kidney disorder was not likely due to Agent Orange exposure or syphilis residuals. The examiner explained that except cancers, acute symptoms related to an exposure usually present at the time of the exposure and then wane rather than initially manifest years following exposure. Further, syphilis did not usually result in renal disease. The examiner concluded that medical literature notes that 70 percent of those with this kidney disorder (retroperitoneal fibrosis) are idiopathic and were either immunoglobulin G4 (IgG4) or non-IgG4 related. In addition, the examiner noted that the renal disease was found incidentally on imaging and opined that the kidney disorder did not result from (not secondary to or aggravated by) PTSD and/or IHD or medications prescribed for these disabilities. The examiner explained that some drugs and infections have been implicated in the kidney disorder but there was no well-documented evidence to support this contention. The examiner concluded that retroperitoneal fibrosis was most likely a manifestation of a systemic autoimmune disease that may arise as a primary aortitis that elicits a periaortic fibroinflammatory response. The examiner noted that hypothesis was supported by the frequent presence of constitutional symptoms, increased concentrations of acute phase reactants, autoantibodies, and known autoimmune diseases. THE EXAMINER IS ADVISED THAT BY LAW, THE MERE STATEMENT THAT THE CLAIMS FOLDER WAS REVIEWED AND/OR THE EXAMINER HAS EXPERTISE IS NOT SUFFICIENT TO FIND THAT THE EXAMINATION IS SUFFICIENT. 3. Schedule the Veteran for a VA examination to determine the nature and likely etiology of the claimed bilateral eye disability. The claims file must be reviewed by the examiner. All indicated tests and studies should be performed and the clinical findings should be reported in detail. A comprehensive clinical history should be obtained, to include a discussion of the Veteran's documented medical history and assertions. The Veteran asserts that his bilateral eye disability onset due to herbicide exposure incurred during service or as secondary (i.e., caused or aggravated by) to his service-connected PTSD and/or IHD. After reviewing the entire record, the examiner should provide an opinion WITH SUPPORTING EXPLANATIONS as to the following: (A) Does the Veteran have a current bilateral eye disability(ies) that onset due to injury or disease (i.e., presumed herbicide exposure) sustained during his period of service? (B) Was the Veteran's current bilateral eye disability(ies) CAUSED OR WORSENED by service-connected PTSD and/or IHD (or medications prescribed for their treatment)? If aggravation of any bilateral eye disability by service-connected PTSD and/or IHD (or medications prescribed for their treatment) is shown, the examiner should objectively quantify, to the extent possible, the degree of aggravation beyond the level of impairment had no aggravation occurred. THE EXAMINER MUST CONSIDER AND EXPLAIN WHETHER THE VETERAN'S ACCOUNT OF THE DEVELOPMENT OF THE DISORDER IS CONSISTENT WITH THE MEDICAL EVIDENCE AND THE EXAMINER'S KNOWLEDGE AND PRACTICE EXPERIENCE, ACCOUNTING FOR FACTS AND CIRCUMSTANCES SPECIFIC TO THE VETERAN. As indicated above, the examiner must review the record in conjunction with rendering the requested opinion; however, his/her attention is drawn to the following: *Service Personnel Records document that the Veteran served in the Republic of Vietnam from January 1968 to March 1969. *An April 1967 service treatment record documents the Veteran's complaint that he had difficulty reading. He reported that his eyes water and felt strained *A February 2015 VA treatment record documents assessment of atrophic retinal hole of the right eye; lattice degeneration without holes right eye; and cataracts both eyes. *A December 2016 VA treatment record documents assessment of large corneal abrasion of the left eye and questionable neurotrophic keratopathy of the left eye. The Veteran complained of a problem with his left eye for approximately one year. *A January 2017 VA treatment record documents assessment of K erosion/epithelial defect of the left eye of uncertain underlying etiology. *August 2018 Report of VA eye conditions examination documents diagnoses of recurrent corneal erosion; cataracts; and, lattice degeneration. The Veteran reported that he had undergone LASIK surgery approximately 20 years earlier. The optometrist opined that the eye disorders were less likely than not incurred in or caused by Agent Orange exposure incurred during service. The optometrist explained that the Veteran's eye conditions onset decades after service and were age-related conditions. The optometrist concluded that the current eye disorders were unrelated to any service-related event or exposure. *The May 2019 VA examination addendum medical opinion documents the optometrist's opinion that the Veteran's eye conditions were unrelated to syphilis and could not be caused by syphilis; were unrelated to PTSD (and medication prescribed for PTSD) and could not be caused by PTSD (and medications prescribed for PTSD); and, were unrelated to IHD (and medications prescribed for IHD) and could not be caused by IHD (and medications prescribed for IHD). *The November 2019 VA addendum medical opinion documents the optometrist's opinion that the Veteran's eye conditions were less likely as not caused by or aggravated by the Veteran's service-connected PTSD and/or IHD (and prescribed medications to treat these service-connected disabilities). The optometrist explained that the eye conditions were unrelated to the Veteran's service-connected PTSD and/or IHD and the PTSD and/or IHD could not cause the eye conditions. THE EXAMINER IS ADVISED THAT BY LAW, THE MERE STATEMENT THAT THE CLAIMS FOLDER WAS REVIEWED AND/OR THE EXAMINER HAS EXPERTISE IS NOT SUFFICIENT TO FIND THAT THE EXAMINATION IS SUFFICIENT. 4. After completion of all actions above, the RO adjudicator must ensure that all remand directives, including those NOTED IN THE COURT'S REMAND, have been completed. Readjudicate the claim and follow all appropriate appellate procedures. Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand by the Court or the Board confers on the veteran or other claimant, as a matter of law, the right to compliance with the remand orders). Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Jackson The Board's actions are binding only with respect to this case. This action is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.