Citation Nr: 21032809 Decision Date: 05/28/21 Archive Date: 05/28/21 DOCKET NO. 19-24 022 DATE: May 28, 2021 REMANDED The request to reopen the issue of entitlement to service connection for a left leg disability, to include leg amputation, lack of blood flow and oxygen, lymphadenitis, and/or cellulitis is remanded. REASONS FOR REMAND The Veteran served on active duty from March to October 1976. In May 2021, the Veteran and his spouse testified under oath before the undersigned Veterans Law Judge at a virtual hearing. At the May 2021 virtual hearing, the Veteran withdrew pending request for documents. Accordingly, the Board may proceed with development of the appeal. As discussed in detail below, there are potentially outstanding relevant service department records. Accordingly, at the present time, the Board does not address the issue of reopening. See 38 C.F.R. § 3.156 (c). The issue has been expanded and recharacterized pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009). The request to reopen the issue of entitlement to service connection for a left leg disability, to include leg amputation, lack of blood flow and oxygen, lymphadenitis, and/or cellulitis. The Board finds that additional development is needed prior to final adjudication of the issue on appeal. First, there may be outstanding relevant service department records to obtain and associate with the claim file. The Veteran has indicated that he was discharged "because of cellulitis of his legs and his right foot swelled up." See CAPRI, April 2009. A VA examination from October 1977 notes "medial discharge for swelling of legs, high blood pressure, 'black out' spells, difficulty breathing running a mile." The Board finds significant that the Veteran served for less than a year, and his separation examination notes "Chapter 5." However, the Veteran's report of medical examination at separation indicates no abnormalities. See STR, September 1976. Given this seeming discrepancy, the Board finds that further investigation is needed regarding the Veteran's separation from service and any diagnoses he may have had at the time of separation. Accordingly, his military personnel records should be obtained. In addition, the Veteran has indicated that he is in receipt of disability benefits from the Social Security Administration (SSA). See Financial Status Report, August 2015. Any relevant records from the SSA should be obtained and associated with the claim file. Further, in VA Forms 21-4142 and 21-4142a, received in December 2020, the Veteran noted treatment at the facilities, L.H. and B.U.M.C.; however, it appears the VA was not able to obtain records from these facilities. See Reports of Contact, January 2021. The Veteran should be updated on the status of his records request and provided an opportunity to submit records. Finally, upon completion of the above development, the Board finds that a VA examination and opinion are needed. Specifically, the Board asks that the Veteran be examined to clarify his left leg diagnosis and to address a potential nexus between any diagnosed leg disability and service. In particular, the Board asks that the examiner address the entrance examination, the diagnoses in service, and any diagnoses that led to his discharge from service. The Board notes that the Veteran's service treatment records indicate abnormal skin, lymphatics, at enlistment. See STR, February 1976. In addition, the Veteran's service treatment records contain diagnoses of cellulitis and lymphadenitis, bilateral legs. See, e.g., STR, July 1976. They also appear to indicate that the lesion(s) dried up and "no cellulitis" after a period of treatment. See STR, July 1976. The matter is REMANDED for the following action: 1. After securing any necessary consent forms from the Veteran, obtain any outstanding military personnel records, and treatment records, to include any VA and/or private treatment records, pertaining to the issue on appeal. In addition, obtain relevant records from the SSA pertaining to any application or award of disability benefits to the Veteran. The Board notes that VA Forms 21-4142 and 21-4142a, received in December 2020, indicate treatment at the facilities, L.H. and B.U.M.C.; however, it appears the VA was not able to obtain records from these facilities. See Reports of Contact, January 2021. The Veteran should be updated on the status of his records request and provided an opportunity to submit records. All efforts should be documented in the claim file. If any records could not be obtained, this should be noted in the claim file. 2. Upon completion of the above, schedule the Veteran for a VA examination to clarify the diagnosis of his claimed left leg disability and to address the etiology of any diagnosed disability(ies). In particular, the Board seeks clarification of whether the Veteran has a disability characterized by lack of blood flow and oxygen to his leg, or if he has lymphadenitis, and/or cellulitis. For each disability diagnosed, the examiner is asked to address whether it is at least as likely as not (i.e., a 50 percent or greater probability) that it was caused by the Veteran's active duty service. In particular, the Board asks that the examiner address any medical issues noted at discharge, if shown upon further development. In addition, the Board notes that the Veteran's service treatment records indicate abnormal skin, lymphatics, at enlistment. See STR, February 1976. Therefore, the Board asks that an examiner address the following regarding the claimed lymphadenitis and/or cellulitis: (a) Whether it is at least as likely as not that the disability(ies) clearly and unmistakably pre-existed service. (b) If there is clear and unmistakable evidence that the claimed disability(ies) preexisted service, then the examiner should address whether there is clear and unmistakable evidence that the claimed disability was not permanently aggravated by service. If not, the examiner should then address whether it is at least as likely as not that it was caused by the Veteran's active duty service. The Board notes that a preexisting injury or disease will be considered to have been aggravated by active service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. See 38 C.F.R. § 3.306 (a). (c) If it is determined that the disability(ies) did not clearly and unmistakably preexist service, then the examiner should address whether it is at least as likely as not that it was caused by the Veteran's active duty service. The examiner is asked to specifically address: (a) The Veteran's service treatment records, including notations of abnormal skin, lymphatics, at enlistment (see STR, February 1976); diagnoses of cellulitis and lymphadenitis, bilateral legs (see, e.g., STR, July 1976), including indications that the lesion(s) dried up and "no cellulitis" after a period of treatment (see STR, July 1976). (b) The June 2019 VA opinion that states that "[h]aving had cellulitis before makes you prone to develop it again" and that "[r]ecurrent episodes of cellulitis may damage the lymphatic drainage system and cause chronic swelling of the affected limb." (c) August 2018 private treatment record that notes cellulitis and discoloration of the left 1-3 toes. The VA examiner should be given access to the claim file. The examiner should state that a review of the claim file was completed. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. A detailed rationale is requested for all opinions provided. 3. If upon completion of the above action the issues is denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Foster, 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.