Citation Nr: 21031102 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 15-31 525 DATE: May 20, 2021 REMANDED Entitlement to service connection for right lower extremity peripheral neuropathy is remanded. Entitlement to service connection for epiretinal membrane is remanded. Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded. REASONS AND BASES FOR REMAND The Veteran had active service in the Army from January 1967 to January 1970. The appeal originates from a November 2013 decision of a Department of Veterans Affairs (VA) Regional Office. In correspondence in November 2019, the Veteran withdrew his request for a Board of Veterans' Appeals (Board) hearing. 1. Entitlement to service connection for right lower extremity peripheral neuropathy is remanded. The Veteran contends that he has right lower extremity peripheral neuropathy caused by unspecified trauma or a documented in-service shrapnel injury to the left knee. See January 2013 Statement. He was afforded a VA examination in September 2013 at which time he was diagnosed with right lower extremity peripheral neuropathy. The examiner provided an opinion on secondary service connection, finding that neuropathy was less likely as not caused by the shrapnel injury. However, the examiner did not address a theory of direct service connection based on any other in-service injury. The Veteran has submitted a January 2018 private DBQ with opinion. The private evaluator opined that the Veteran's right lower extremity peripheral neuropathy is due to various in-service injuries. However, the evaluator indicated that the neuropathy was diagnosed in August 1968 during service and based the opinion in part on the existence of "subsequent neuropathy residuals." Yet there does not seem to be any such diagnosis in the service treatment records or in the evaluator's summary of the Veteran's medical history. It also does not appear that the Veteran reported an in-service diagnosis on examination in August 2013. The Veteran has also submitted a November 2019 private DBQ in which the examiner opined that the Veteran's lower extremity neuropathy likely steams from traumatic, active duty etiology. The examiner noted that the Veteran's symptoms began at a young age and are otherwise largely idiopathic, persistent symptoms. No additional rationale was discussed. The Board has considered the private opinions but finds that a remand is needed to obtain a new VA opinion that considers all theories of entitlement. 2. Entitlement to service connection for epiretinal membrane is remanded. The Veteran contends that he has a right eye disorder secondary to his service-connected traumatic brain injury (TBI). See January 2013 Statement. He was afforded a VA examination in August 2013 and diagnosed with epiretinal membrane on the right. Though the examiner provided an opinion on secondary service connection, aggravation by the TBI is not addressed. In addition, the Veteran has claimed that his epiretinal membrane is secondary to his service-connected scar, laceration to scalp. See January 2016 Statement. No VA opinion has been obtained specific to this theory. Based on the forgoing, the Board finds that a remand is needed to obtain an addendum VA opinion. 3. Entitlement to a rating in excess of 30 percent for PTSD is remanded. The Veteran was afforded a VA psychiatric examination in August 2013. He has since submitted private evaluations in October 2017 and November 2019 that indicate that his symptoms have become more severe. As there appears to be a worsening of his disability, he should be afforded a new VA examination. The matters are REMANDED for the following action: 1. Obtain a new VA opinion as to the etiology of the Veteran's right lower extremity peripheral neuropathy. The examiner is asked to address the following: a. Is it at least as likely as not that right lower extremity peripheral neuropathy had its onset in service or within a year of service discharge or is otherwise etiologically related to active service? b. Is it at least as likely as not that right lower extremity peripheral neuropathy was caused by the service-connected TBI or shell fragment wound to the left lower extremity? c. Is it at least as likely as not that right lower extremity peripheral neuropathy underwent any incremental increase in disability, regardless of its permanence, due to the service-connected TBI or shell fragment wound to the left lower extremity? A full rationale must be provided for all options expressed. The examiner should discuss the January 2018 and November 2019 private opinions. 2. Request an addendum opinion from the August 2013 eye examiner, or if unavailable, another suitably qualified examiner. The examiner is asked to address the following: a. Is it at least as likely as not that epiretinal membrane OD had its onset in or is otherwise etiologically related to active service? b. Is it at least as likely as not that epiretinal membrane OD was caused by the service-connected TBI or scar, laceration to scalp? c. Is it at least as likely as not that epiretinal membrane underwent any incremental increase in disability, regardless of its permanence, due to the service-connected TBI or scar, laceration to scalp? A full rationale must be provided for all options expressed. (Continued on the next page) 3. Schedule the Veteran for a VA psychiatric examination to evaluate the current nature and severity of his disability. The examiner is asked to provide a retrospective opinion for the period on appeal, particularly since the last VA examination in September 2013, as to the nature and severity of the Veteran's disability, including a discussion of any changes in symptomatology and severity during the period on appeal. The examiner should consider the October 2017 and November 2019 private evaluations. A full rationale must be provided for all options expressed. Amanda Christensen Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Alhinnawi, Mohammad 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.