Citation Nr: 21032420 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 16-46 952 DATE: May 27, 2021 REMANDED Service connection for a claimed disability of the left lower extremity, to include neuropathy and any current disability of the left ankle, claimed as the result of in-service exposure to extreme cold. Service connection for a claimed disability of the right ankle, claimed as the result of in-service exposure to extreme cold. Service connection for a claimed disability of the right upper extremity, to include neuropathy and any other disability manifested by weakness of the right hand, claimed asa result of in-service exposure to extreme cold. Service connection for a claimed disability of the left upper extremity, to include neuropathy and any other disability manifested by weakness of the left hand, claimed asa result of in-service exposure to extreme cold. Service connection for a claimed disability of the bilateral eyes. REASONS FOR REMAND The Veteran served on active duty from March 1964 to March 1966. This case is on appeal from a rating decision issued in November 2014. The Board remanded this case for further development in March 2018 and January 2021. The Board explained in both remands why it had consolidated and reorganized the Veteran's service connection claims for purposes of clarity and efficiency. 1. Service connection for a claimed disability of the left lower extremity, to include neuropathy and any current disability of the left ankle, claimed as the result of in-service exposure to extreme cold. 2. Service connection for a claimed disability of the right ankle, claimed as the result of in-service exposure to extreme cold. 3. Service connection for a claimed disability of the right upper extremity, to include neuropathy and any other disability manifested by weakness of the right hand, claimed asa result of in-service exposure to extreme cold. 4. Service connection for a claimed disability of the left upper extremity, to include neuropathy and any other disability manifested by weakness of the left hand, claimed asa result of in-service exposure to extreme cold. With regard to potentially missing VA medical records, the Veteran wrote in his May 2015 notice of disagreement (NOD) that he first received treatment at his VA Medical Center (VAMC) upon separation from service. The Board is unable to locate any requests by the RO for records beginning after his March 1966 separation from service. The available VA medical records in the file currently begin from October 2013. Upon remand, a request for these records must be made. Relatedly, the updated VA medical records show that the Veteran has had considerable private (non-VA) treatment for the claimed conditions. See 12/10/2020 VA Primary Care; 11/13/2013 VA Primary Care. These medical records now appear relevant as a January 2021 VA examiner relied on a history of symptoms existing for only 5 years; the private medical records would likely contain further information regarding any earlier history of the conditions. Finally, the Board finds that a new VA examination is warranted. As indicated, the Veteran underwent a VA examination in January 2021 pursuant to the Board's January 2021 remand. The VA examiner gave a negative opinion reasoning that the onset of symptoms was 5 years prior. This was the critical fact underpinning the VA examiner's opinion as seen by the rationale, which went into great detail explaining why cold related injuries would have manifested closer in time to the injury. This appears to be a factual error on the examiner's part, however, as the available private medical records document symptoms as early as February 2007. This was greater than 14 years prior to the January 2021 VA examination, which is much earlier than the 5 years relied on by the examiner. In fact, the Veteran has written in support of his claim that his symptoms have existed since service with treatment first sought immediately after service. The Board is remanding to attempt to obtain these records. Without considering this information, it cannot be found that the January 2021 VA examiner's opinion is based on a complete and accurate factual foundation. Hence, remand is warranted for a new VA opinion. 5. Service connection for a claimed disability of the bilateral eyes. This issue is also remanded to attempt to obtain potentially missing private medical records. Multiple VA medical records refer to past and ongoing treatment with private medical providers. See 1/30/2020 VA Eye Note (treatment by Dr. Boada, Dr. Vaquer); 11/13/2013 VA Primary Care (treatment by private ophthalmology). As the private treatment appears to have been the primary care for his eye conditions, these medical records are likely to contain extensive evidence regarding the history and development of the disease. The missing medical records appear important because a prior VA examiner, who gave a negative opinion in October 2019, reasoned primarily from the premise that the STRs were silent for the conditions and that the Veteran had not been diagnosed until "many years after his active service." If these medical records are obtained, the Board finds that a new VA opinion will be warranted. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for any private (non-VA) providers or facilities who have treated him in the past for his claimed conditions, including Dr. Boada, Dr. Vaquer, Dr. Cidre, and the (unnamed) physiatrist who conducted an EMG in December 2020; . Make two requests for any authorized records, unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran's outstanding VA treatment records since the Veteran's separation from service, including records of all treatment obtained through VA's Choice program and all paper records scanned into his electronic health record. 3. Schedule the Veteran for an examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) by an appropriate clinician to determine the nature and etiology of the claimed cold injury residuals. For each diagnosis, the examiner must address whether the disorder at least as likely as not (1) began during active service, (2) manifested within 1 year after discharge from service, (3) was noted during service with continuity of the same symptomatology since service, or (4) , is otherwise related to an in-service injury, event, or disease. In answering these questions, the examiner is asked to consider the statements from the Veteran indicating that symptoms started during service. The examiner is asked to explain why his statements make it more or less likely that a current condition started during service. If indicated, it should be explained whether there is a **medical** reason to believe that the Veteran's recollection of his symptoms during and after service may be inaccurate or not medically supported as the onset or cause of his current diagnosis. The examiner should not rely on silence in the medical records unless it can be explained: (a) why the silence in the available records can be taken as proof that the symptom(s) did not occur, including why the fact would have normally been recorded if present, or (b) why the absence of medical records is medically significant. 4. If VA records since service and the identified private medical records are obtained, obtain a new VA opinion to address whether a current eye condition at least as likely as not is related to service. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Bosely, 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.