Citation Nr: 21032153 Decision Date: 05/26/21 Archive Date: 05/26/21 DOCKET NO. 16-05 908 DATE: May 26, 2021 ORDER Entitlement to service connection for neuropathy of cranial nerve, claimed as peripheral neuropathy of the face, to include as due to exposure to Agent Orange, is denied. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with traumatic brain injury (TBI), prior to November 20, 2019, and a rating in excess of 70 percent thereafter is denied. REMANDED Entitlement to service connection for left upper neuropathy, claimed as peripheral neuropathy of the arm and hand, to include as due to exposure to Agent Orange, is remanded. Entitlement to service connection for right upper neuropathy, claimed as peripheral neuropathy of the arm and hand, to include as due to exposure to Agent Orange, is remanded. FINDINGS OF FACT 1. There has been no demonstration by competent clinical evidence, or competent and credible lay evidence, of a current diagnosis of cranial nerve neuropathy at any time proximate to, or since the Veteran's claim. 2. Prior to November 20, 2019, the Veteran's PTSD with TBI was manifested by occupational and social impairment comparable to occupational and social impairment with reduced reliability and productivity. 3. From November 20, 2019, the Veteran's PTSD with TBI has been manifested by occupational and social impairment comparable to occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. CONCLUSIONS OF LAW 1. The criteria for service connection for neuropathy of cranial nerve have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5107; 38 C.F.R. § 3.303. 2. Prior to November 20, 2019, the criteria for an initial rating in excess of 50 percent for PTSD with TBI have not been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.130, Diagnostic Code 8045-9411. 3. From November 20, 2019, the criteria for an initial staged rating in excess of 70 percent for PTSD with TBI have not been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.130, Diagnostic Code 8045-9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1965 to March 1969. This matter came to the Board of Veterans' Appeals (Board) on appeal from August 2014 and October 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In November 2019, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is associated with the record. These matters were last before the Board in April 2020, whereupon the issues on appeal were remanded to the RO for further development. Upon the issuance of an October 2020 supplemental statement of the case, the case was returned to the Board for its adjudication. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Secondary service connection is warranted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). The threshold legal requirements for a successful secondary service connection claim are: (1) evidence of a current disability for which secondary service connection is sought; (2) a disability for which service connection has been established; and (3) competent evidence of a nexus between the two. 1. Entitlement to service connection for neuropathy of cranial nerve, claimed as peripheral neuropathy of the face, to include as due to exposure to Agent Orange. The Veteran contends that he has cranial nerve neuropathy manifested by pain, tingling and numbness in the face, that either is related to service-connected TBI or the result of his exposure to Agent Orange during his tour of duty in Vietnam. The Board concludes that the Veteran does not have a current diagnosis of a chronic disorder and has not had one at any time during the pendency of the claim or recent to the filing of the claim. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (holding that the requirement a current disability is satisfied when the claimant has the disability at the time the claim for VA disability compensation is filed or during the pendency of the claim and that a claimant may be granted service connection even though the disability resolves prior to VA's adjudication of the claim); Romanowski v. Shinseki, 26 Vet. App. 289, 294 (2013). The Veteran's claim was received in June 2014. The record reflects that during a December 2011 VA electromyography (EMG) consultation, the Veteran reported numbness and tingling in the face. The EMG study only revealed evidence of bilateral sensorimotor medial mononeuropathies at the wrist (carpal tunnel syndrome (CTS)). In a January 2012 VA neurology consultation report, the Veteran described numbness and tingling from his neck to the top of his head. It was noted that the Veteran had previously undergone a brain magnetic resonance imaging (MRI) which found no abnormalities and EMG which identified bilateral CTS. Concerning this, the Board notes that an October 2011 MRI of the brain found signal alternations in the right frontal matter, nonspecific, could be related to an ischemic insult or prior trauma. On neurological examination, cranial nerves II-XII were found to be intact. The physician noted that the etiology of the Veteran's facial paresthesias remained unclear, but she could not rule out the possibility of psychogenic contribution to the Veteran's symptoms or non-neurologic etiologies, including rheumatologic or endocrinologic diagnoses, or vitamin deficiencies. In August 2015, the Veteran was provided a Cranial Nerves Diseases examination. The examiner noted that the Veteran does not now have or has ever been diagnosed with a cranial nerve condition. The Veteran reported that about seven to eight years prior, his face felt like it went totally numb and his head and scalp would feel strange. His arms and fingers also did not feel normal and he was evaluated by neurology and was told he had carpal tunnel syndrome (CTS). He currently had symptoms of constant pain, paresthesias, and/or dysesthesias in the face that was moderate in severity. Significantly, the examiner found that the Veteran's claimed cranial nerve condition did not impact his ability to work. Muscle strength and sensory examination was all normal. Upon cranial nerve evaluation, the examiner indicated that the Veteran's cranial nerves were not affected. The Board remanded this matter to obtain a medical opinion to identify a medical diagnosis. Most recently, in an October 2020 addendum, a VA physician provided an opinion that the Veteran does not have a diagnosis of cranial neuropathy. Although he asserts he has been experiencing facial symptoms since service, due to a fall or due to exposure to Agent Orange, the medical evidence of record shows no history of neurology consultation or treatment for, or discussion regarding the claimed symptoms since leaving service in 1969. Regarding the 2011 brain MRI noting ischemic changes or possible signal increase due to history of trauma, the examiner indicated that these findings do not explain the underlying complaints reported by the Veteran. Based on the foregoing, the examiner concluded that there is no objective evidence of an underlying cranial nerve condition based on review of the evidence of record. While the Veteran believes he has a current diagnosis of cranial nerve neuropathy, he is not competent to provide a diagnosis in this case. Though the Veteran may be competent and credible to describe the particular symptoms from which he suffers, determining the exact nature and diagnosis of a neurological disorder requires specialized medical education/knowledge or training which the Veteran is not shown to have. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Here, the 2020 VA examiner provided an opinion that the Veteran's symptoms of facial pain and numbness do not warrant a diagnosis of cranial nerve neuropathy. Consequently, the Board gives more probative weight to the competent medical evidence. In reaching this conclusion, the Board finds that there is simply no evidence of record showing a current diagnosis of chronic disorder manifested by cranial nerve neuropathy. Further, no functional impairment has been argued or shown. See Saunders v. Wilkie, 886 F.3d 1356, 1367-69 (Fed. Cir. 2018) (holding that "pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability" if it "reaches the level of a functional impairment of earning capacity."). Because entitlement to service connection requires the presence of a current disability, the Board finds that service connection for cranial nerve neuropathy, to include due to exposure to Agent Orange, has not been established. See Brammer v. Derwinski, 3 Vet. App. 223 (1992) (indicating that service connection presupposes a current diagnosis of the condition claimed). Thus, service connection for cranial nerve neuropathy is not warranted. Increased Rating Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Evaluation of a service-connected disability requires a review of a veteran's medical history with regard to that disorder. However, the primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. While the entire recorded history of a disability is important for more accurate evaluations, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where a veteran appeals the initial rating assigned for a disability, evidence contemporaneous with the claim and the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." See Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time. Id. 2. Entitlement to an initial rating in excess of 50 percent for PTSD with traumatic brain injury TBI, prior to November 20, 2019, and an initial staged rating in excess of 70 percent thereafter. Service connection for PTSD was established by the August 2014 rating decision, which assigned an initial rating of 50 percent from June 22, 2012, under the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130, Diagnostic Code 9411. In an October 2015 rating decision, the RO recharacterized the disability as PTSD with TBI and continued the 50 percent rating under Diagnostic Code 8045-9411. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. Here, the hyphenated diagnostic code indicates that TBI (Diagnostic Code 8045) is rated under the criteria for psychiatric disorders (Diagnostic Code 9411). Ratings are assigned according to the degree of occupational and social impairment resulting from manifestations of the disability at issue. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Under the provisions for rating psychiatric disorders, a 50 percent disability rating requires evidence of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting; inability to establish and maintain effective relationships.). Id. A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign a rating based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126. The evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including (if applicable) those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). See Mauerhan, 16 Vet. App. 436. Effective August 4, 2014, VA amended the portion of the Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and replaced them with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094 (August 4, 2014). The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the Agency of Original Jurisdiction (AOJ) on or after August 4, 2014. The provisions of this interim final rule apply to claims that had been certified for appeal to the Board prior to August 4, 2014. VA adopted as final, without change, the interim final rule, effective March 19, 2015. 80 Fed. Reg. 53, 14308 (March 19, 2015). This appeal was certified to the Board in February 2016. As such, the provisions of DSM-5 are for application. Prior to November 20, 2019 The Veteran underwent a VA examination in August 2013. The examiner noted diagnoses of chronic major depression and generalized anxiety disorder. The examiner noted that with regard to all mental diagnoses, the Veteran's occupational and social impairment was best summarized as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. At the time of the examination, the Veteran reported that he had been married to his third wife for eight years and the wife stated that the Veteran socialized relatively well with her family. He reported he was close to his wife and her three sons but had no friends. He maintained distant contact with three men with whom he served in Vietnam. He enjoyed vegetable gardening and bike riding. He had been a truck driver for most of his life after service and last worked approximately one and half years before. The Veteran was currently attending individual and group psychotherapy, but had no psychiatric hospitalizations. The Veteran endorsed a history of being sad most days, excessive worry, and irritability. On mental status examination, the Veteran was fully oriented and clean with good hygiene. His behavior was appropriate, cooperative, and pleasant. Impulse control and psychomotor activity were normal. His eye contact was fair to good. He denied suicidal or homicidal ideation, paranoid ideation or hallucination, or delusions. His form of thought was linear and adequate. His attention, concentration, abstract reasoning, memory, judgment, and insight were fair. Current symptoms included depressed mood, anxiety, chronic sleep impairment, and impaired impulse control, such as unprovoked irritability with periods of violence. The VA examiner stated that the Veteran was capable of managing his financial affairs. A May 2014 Vet Center record shows the Veteran's symptoms of anxiety, persistent intrusive memories, marked withdrawal from a broad range of social activities, hyperarousal symptoms, including sleep problems, excessive startle response, difficulty relaxing, and deep depression. He showed no behavior consistent with mania or psychosis. During an August 2015 VA examination, the Veteran reported that his marital and social status remained essentially unchanged since the previous evaluation in August 2014. He resided with his wife and did not socialize much with others. He remained retired but attempted to stay busy with household chores and yardwork. His wife indicated that he became more forgetful and depressed. The examiner found him to have occupational and social impairment with reduced reliability and productivity. The Veteran's symptoms were depression, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, and flattened affect. On behavioral observation, the Veteran was groomed appropriately, and eye contact was appropriate. He was generally articulate. The examiner also indicated that the Veteran was easily distracted and exhibited obsessional thinking. The VA examiner stated that the Veteran was capable of managing his financial affairs. The Veteran underwent a private psychological evaluation in May 2018. He was fully oriented, and no disturbances were noted in attention and concentration. Eye contact was diminished during the interview. His grooming and hygiene were appropriate. His memory was grossly intact. His affect was flat. He reported no suicidal or homicidal ideation. His thought content was appropriate for the situation and his thought processes were tangential. Judgment, reasoning, and insight were adequate. The diagnoses were chronic PTSD and major depressive disorder, recurrent, unspecified. By applying the Veteran's psychiatric symptomatology to the rating criteria described above, the Board finds that his total disability picture most closely approximates the criteria for a 50 percent rating prior to November 20, 2019. In this regard, the Board determines that the Veteran's psychiatric disability has been productive of symptomatology resulting in functional impairment comparable to occupational and social impairment with reduced reliability and productivity, without more severe manifestations that more nearly approximate functional impairment comparable to occupational and social impairment with deficiencies in most areas or total occupational and social impairment. The Veteran's total disability picture does not rise to the severity required for a 70 percent or higher rating. In this regard, the Board finds that occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, has not been shown. Notably, the August 2015 VA examiner opined that the Veteran's level of occupational and social impairment with regard to his mental diagnosis was best summarized as occupational and social impairment with reduced reliability and productivity. In this regard, the Board recognizes that a disability rating is based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's characterization of symptoms. The Veteran's PTSD with TBI impacted his social and occupational functioning due to irritability and social withdrawal. However, the evidence also shows that the Veteran had a very positive and supportive family relationships. While the clinical findings of record describe experiences, thoughts, and emotions due to PTSD with TBI that had noticeable impact on the Veteran's social relationships, the evidence, overall shows that he was able to function well in his daily activities. In other words, the Veteran's reported inability to have meaningful relationship suggests difficulty in establishing and maintaining effective work and social relationships with reduced reliability and productivity, but not occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood, as is required for the next higher rating of 70 percent. See Bowling v. Principi, 15 Vet. App. 1, 11 (2001). Regarding the Veteran's occupational functioning, the Board notes that total occupational impairment due to PTSD with TBI was not shown. The Veteran had not worked since 2012 after a long history of working as a truck driver. However, he did not indicate that he had to quit his job due to his PTSD symptoms. Further, the VA examiner indicated that the Veteran had been capable of managing his financial affairs and the Veteran did not report significant impairment of his usual daily activities, although he experienced occasional impairment because of symptoms of PTSD. After reviewing the Veteran's statement and the clinical findings at the VA examination, the Board finds that the Veteran's presentation was consistent with occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks. The Board also finds it significant that no abnormalities were found with regard to the Veteran's thought processes, speech, and communication. He was capable of managing his financial affairs. The record shows that his speech was normal, his thought process was organized with no unusual content, and his judgment and insight were normal. He was oriented and there were no delusions or hallucinations. Mental status examination indicated that there was no obvious gross impairment in orientation, attention, and memory. Thus, deficiencies in the areas of judgment or thinking were not shown. Other symptoms demonstrative of the level of functional impairment required for a higher 70 percent rating were neither complained of nor observed by medical health care providers, including obsessional rituals; illogical, obscure, or irrelevant speech; impaired impulse control; suicidal ideation; or periods of violence. The Veteran has not been shown to have symptoms equivalent in nature or severity to the criteria required for a higher rating. The record shows the Veteran's disability was found to be consistently manifested by symptoms of anxiety, irritability, flattened affect, mild memory loss, and sleep impairment as well as depressed mood. The evidence does not otherwise show speech suggestive of disorders of thought or perception, difficulty understanding commands, or impairment of memory or abstract thinking. Accordingly, the Board finds that prior to November 20, 2019, the Veteran's impairment due to PTSD with TBI is more consistent with a 50 percent rating and that the level of disability contemplated in Diagnostic Code 9411 to support the assignment of a 70 percent or rating or higher is absent. From November 20, 2019 Forward During his November 2019 Board hearing, the Veteran testified that his PTSD with TBI symptoms worsened. He stated his memory was very poor and he became very forgetful. An October 2020 VA examination report noted a diagnosis of PTSD. The Veteran reported frequent forgetfulness, short term memory difficulties, nightmares, frequent difficulty sleeping, intrusive memories, avoidance behaviors, and negative alternations of thoughts and mood. The examiner found that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, and/or mood with regard to all mental diagnoses. The Veteran reported a good marital relationship and that he relied heavily on his spouse. He stated he was not currently employed and his last employment as a truck driver was ten years before. The Veteran's symptoms included depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, chronic sleep impairment, mild memory loss, flattened affect, impaired judgment, disturbance of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances, to include work or a work like setting. On behavioral observation, the Veteran was pleasant and cooperative. He was dressed appropriately. His mood appeared depressed with irritable affect. He was tangential and perseverative in his thought process, and reported recent difficulty with poor judgment. His speech was normal. There was no evidence of delusions or hallucinations. He showed good eye contact and interacted appropriately. He denied current suicidal or homicidal ideation. He had the ability to maintain minimal personal hygiene and other basic activities of daily living. He was fully oriented and reported ongoing difficulty with short term memory. He was found capable of managing his financial affairs. Based on the foregoing evidence for the period from November 20, 2019, the Board finds that the functional impairment resulting from the Veteran's PTSD with TBI most closely approximates the criteria for a 70 percent disability rating and does not rise to the severity required for a 100 percent rating. 38 C.F.R. § 4.7. In this regard, the Board finds that functional impairment comparable to total social and occupational impairment has not been shown in this case. The Board finds it significant that the October 2020 VA examiner noted that the Veteran's PTSD with TBI resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. Although the June 2019 VA examiner provided an opinion that the Veteran had significant social impairment, as evidenced by his social isolation, he has been able to maintain a very positive marital relationship. Accordingly, while the Veteran has shown substantial social and occupational impairment, the evidence does not demonstrate total social and occupational impairment. See 38 C.F.R. § 4.130, Diagnostic Code 9411. The October 2020 VA examination report also reflects that the Veteran was able to follow the demands of the interview with appropriate attention and concentration. His basic memory and concentration skills were intact with no impairment noted. His speech was normal, and he was able to maintain minimal personal hygiene and other basic activities of daily living. Nor does the credible lay and medical evidence demonstrate gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, or disorientation to time and place, as reflected by the October 2020 VA examination report. On mental status examinations, the Veteran was alert and fully oriented, with no evidence of psychomotor agitation or retardation. No evidence of hallucinations, delusions, or specific obsessions, compulsions, phobias, or ritualistic behaviors were present. As such, the evidence does not support a finding of total occupational and social impairment that is the criteria for a 100 percent rating for PTSD with TBI. Accordingly, considering the evidence in totality, the Board finds that the Veteran's disability picture more nearly approximates the criteria for the 70 percent disability rating, and therefore the 70 percent rating is the appropriate rating. 38 C.F.R. § 4.7. REASONS FOR REMAND 1. Entitlement to service connection for left upper neuropathy, claimed as peripheral neuropathy of the arm and hand, to include as due to exposure to Agent Orange, is remanded. 2. Entitlement to service connection for right upper neuropathy, claimed as peripheral neuropathy of the arm and hand, to include as due to exposure to Agent Orange, is remanded. The Board remanded these claims in April 2020 to obtain a new VA medical opinion as to the etiology of the Veteran's upper extremity neuropathy, including to address the Veteran's contentions. In this regard, the Veteran contends that his bilateral upper extremity neuropathy are residuals of TBI incurred when he fell from a ladder and hit his head on a steel deck aboard a ship in 1967, or are the results of his exposure to Agent Orange during his tour of duty in Vietnam. A VA examination and a medical opinion was obtained in September 2020. The September 2020 VA examiner noted that the Veteran had a diagnosis of bilateral CTS which is caused by median nerve compression at the wrist, and there is no pathophysiologic association for an aggravation to be caused by PTSD and a mild TBI during service. The examiner also stated that there were no records to show association between bilateral CTS and his Agent Orange exposure and that there were no medical information supporting correlation between CTS and the Veteran's Agent Orange exposure. This opinion is conclusory and not well-supported. Specifically, the examiner does not provide the necessary underlying medical explanation as to why the evidence of record does not support relationship of the Veteran's bilateral CTS to his service-connected TBI or Agent Orange exposure in service. See Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012) (holding that "examination reports are adequate when they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion"). Consequently, a new medical opinion is requested. The matters are REMANDED for the following actions: 1. Obtain any updated VA treatment records and associate these records with the claims folder. All attempts to obtain these records must be documented in the claims file. 2. Forward the claims file to the VA examiner who conducted the September 2020 VA examination or, if unavailable, to another VA examiner with the necessary medical expertise. The entire claims file must be provided to the examiner, and the report must reflect a review of the entire records was accomplished. If the examiner determines an additional physical examination of the Veteran would be beneficial, one is to be arranged. Any clinically indicated tests and/or consultations must be performed. Following a review of the claims file and physical examination of the Veteran if deemed necessary, the examiner should offer an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's current bilateral CTS (i) was either caused by, or aggravated by, his service-connected TBI; or (ii) is etiologically related to his period of active service, to include his exposure Agent Orange while serving in Vietnam. The examiner must provide separate findings and rationales relating to causation and aggravation. Aggravation does not require that there be "permanent" worsening of the nonservice connected disability. In offering this opinion, the examiner is reminded that the Veteran is presumed to have been exposed to herbicide agents during his military service in Vietnam. The Veteran is competent with regard to any statements as to onset and symptoms. The examiner is asked to elicit information from the Veteran regarding current symptoms and complaints through the years, and fully consider the Veteran's lay statements regarding the onset and symptoms of the claimed disability. The examiner should address whether any claimed symptoms in service are consistent with any current disorder. If there is a clinical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. (Continued on the next page) A complete rationale must be offered for the opinion expressed, including a discussion of the evidence and medical principles which led to the conclusions reached. 3. After completing the above, and any other development deemed necessary, readjudicate the claims on appeal based on the entirety of the evidence. If any benefits sought on appeal are not granted to the Veteran's satisfaction, he and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. J. In, 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.