Citation Nr: 21032737 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 09-16 631 DATE: May 27, 2021 REMANDED Entitlement to service connection for a left leg disability other than a skin disorder, to include restless leg syndrome, is remanded. Entitlement to service connection for a right leg disability other than a skin disorder, to include restless leg syndrome, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from February 1970 to October 1971, with additional service in the Reserves. This case comes before the Board of Veterans' Appeals (Board) from April 2008 and July 2010 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In May 2011, February 2016, January 2010, and October 2020, the Board remanded these claims for further evidentiary development. 1. Entitlement to service connection for a bilateral leg disability other than a skin disorder, to include restless leg syndrome, is remanded. The Veteran contends he is entitled to service connection for right and left leg disabilities, to include restless leg syndrome. Initially, there is a question as to whether he in fact has a current leg disability. There is also an open question as to whether his current symptoms are related to a note found in the Veteran's pre-service examination discussing post-exercise leg cramps. The Veteran received a C&P examination in February 2020 during which he was diagnosed with restless leg syndrome; the examiner issued a contradictory opinion as discussed in the Board's October 2020 remand. In March 2021, the Veteran was given another C&P examination; the examiner determined (a) the Veteran did not have a diagnosed leg disability; and (b) his bilateral leg disability, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression during service, as there was no bilateral leg condition to diagnose on the exam that day. The Board finds yet another examination is needed, because, regrettably, the March 2021 C&P findings are inadequate. The examiner stated the Veteran's symptoms had resolved. Even if true, this would not necessarily preclude an award of service connection. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that the threshold requirement for service connection is met when a disability exists at a time the claim was filed, even if it resolves prior to adjudication of the claim). Moreover, the March 2021 C&P findings are in conflict with the Veteran's most recent VA medical records, which noted in October 2020 that he was still taking medication for restless leg syndrome; this medication is found throughout the Veteran's VA medical records. The Veteran also has a long history of reporting leg pain. For example, in April and August 2019 he was seen with symptoms of leg pain and "jerking" during waking hours. The Board recognizes the Veteran reported he was not experiencing symptoms at the time of the March 2021 C&P examination. This fact alone is not dispositive. An additional examination is in order to determine whether the Veteran has ever had functional impairment of his legs at any time during the appeal period (dating back to 2007). Once VA undertakes to provide a medical opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (207). Even if the examiner determines the Veteran's disability is in remission at the time of the examination, given that the Veteran has been taking medication for restless leg syndrome since at least 2019 and has complained of leg pain long before that, it is simply not adequate to base a negative nexus opinion on a finding of no current disability at the time of a 2021 examination. 2. Entitlement to a TDIU is remanded. The Veteran's claim of entitlement to a TDIU is inextricably intertwined with the issues addressed above and will be remanded. See Harris v. Derwinski 1 Vet. App. 180, 183 (1991) (holding that issues are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination by an examiner to determine the nature and etiology of the Veteran's bilateral leg disability other than skin disorder. The examiner is asked to review the claims file and provide the following information: (a) State whether the criteria for a diagnosis have been met at any time during the pendency of the appeal. In reaching this conclusion, the examiner must discuss the Veteran's long history of leg complaints, as well as his history of taking Ropinerole since at least 2019 for restless leg syndrome. (b) Opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's disability was incurred in or otherwise related to the Veteran's service. (c) If it is determined that there is another likely etiology for the Veteran's disability, that should be stated. The examiner should set forth all examination findings, with a clear rationale for the conclusions reached. 2. Following this examination and any additional indicated development, adjudicate the issues on appeal, including the issue of entitlement to a TDIU. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Ryan, Associate 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.