Citation Nr: 22010551 Decision Date: 02/24/22 Archive Date: 02/23/22 DOCKET NO. 07-24 202 DATE: February 24, 2022 REMANDED Entitlement to an evaluation in excess of 10 percent for residuals of a right wrist fracture with degenerative changes and loss of motion is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1975 to July 1976. This matter is before the Board of Veterans' Appeals (Board) on appeal of an August 2006 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran testified before the undersigned during a May 2009 hearing. Most recently, the Board remanded this matter in May 2021 for further development. The case has been returned to the Board at this time for further appellate review. The Board notes that, in the November 2021 Informal Hearing Presentation, the Veteran's representative asserted that the most recent VA examinations (obtained in August 2021) are insufficient because the examiner was a nurse practitioner, and thus, her expertise did not lend well to the administration of the examination. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that a Veteran is required to raise a specific challenge to the competency of a VA examiner before VA is required to respond with information about the qualifications of the examiner. See Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011); Francway v. Wilkie, 940 F.3d 1304 (Fed. Cir. 2019) (finding that a Veteran is required to challenge a VA examiner's competence in the first instance). To the extent the November 2021 IHP is a request for information, it does not raise a specific challenge, thus, VA is not required to provide information about the VA examiner. Entitlement to an evaluation in excess of 10 percent for residuals of a right wrist fracture with degenerative changes and loss of motion is remanded. This matter was most recently remanded in order to obtain an opinion regarding the nature and etiology of the Veteran's rheumatoid arthritis (RA). Specifically, the examiner was asked to opine as to whether the symptoms of the Veteran's RA can be clearly delineated from the symptoms of his service-connected residuals of a right wrist fracture with degenerative changes and loss of motion, and if so, whether it is at least as likely as not that the Veteran's RA is (a) caused by; or (b) aggravated by the Veteran's service-connected residuals of a right wrist fracture with degenerative changes and loss of motion. Pursuant to the Board remand, a VA examination was obtained in August 2021 which the Board finds is inadequate for the following reasons. First, it appears to be internally inconsistent as to the manifestations of the Veteran's RA. Specifically, the examiner first notes that there is no joint involvement present, however, the examiner later states that the RA is manifested by constitutional manifestations associated with active joint involvement which are totally incapacitating. Without further information, it is unclear to the Board whether the Veteran's joints are involved in the symptomatology of the Veteran's RA. Second, the VA examiner did not opine as to whether the symptoms of the Veteran's RA can be clearly delineated from the symptoms of his service-connected residuals of a right wrist fracture with degenerative changes and loss of motion. Thus, the VA examiner did not comply with the Board's prior remand directives. Finally, the Board finds that the VA examiner's opinion that it is likely that the Veteran's natural progression of RA was aggravated at least in part by his service-connected residuals of a right wrist fracture with degenerative changes and loss of motion is not supported by a sufficient rationale. The examiner states that the Veteran has severely limited mobility, range of motion in the right wrist and there is edema. The examiner then states that edema is likely caused by and aggravated at least in part by his service-connected residuals, fractured right wrist with degenerative changes and loss of motion. It is unclear what the relationship is, if any, between the right wrist edema and the rheumatoid arthritis, particularly if the Veteran's RA does not involve the Veteran's right wrist joint. For these reasons, the Board finds that remand is warranted for a new VA opinion. This matter is REMANDED for the following action: Obtain an opinion with a qualified clinician who has not previously opined about the Veteran's claim to determine the nature and etiology of the Veteran's rheumatoid arthritis of the right wrist. If the selected clinician determines that an examination is necessary to respond to this request, such examination should be scheduled. Following review of the claims file, and examination of the Veteran if deemed necessary, the examiner should first opine as to whether the Veteran has right wrist symptoms from rheumatoid arthritis in addition to the right wrist symptoms from his service-connected residuals of a right wrist fracture with degenerative changes and loss of motion. If so, the VA examiner should opine as to whether the right wrist symptoms of the Veteran's rheumatoid arthritis can be clearly delineated from the right wrist symptoms of his service-connected residuals of a right wrist fracture with degenerative changes and loss of motion. If the right wrist symptoms from the rheumatoid arthritis cannot be clearly delineated from the right wrist symptoms of the service-connected residuals of a right wrist fracture with degenerative changes and loss of motion, this must be expressly stated. If they can be clearly delineated, the examiner must describe the right wrist symptoms attributable to each diagnosis. If the examiner finds that the right wrist symptoms of the Veteran's rheumatoid arthritis can be clearly delineated from the right wrist symptoms of his service-connected residuals of a right wrist fracture with degenerative changes and loss of motion, the examiner should opine whether it is at least as likely as not (at least an approximate balance of the positive and negative evidence) that the Veteran's rheumatoid arthritis of the right wrist is (a) caused by; or (b) aggravated (i.e., worsened beyond the normal progression of the disease) by the Veteran's service-connected residuals of a right wrist fracture with degenerative changes and loss of motion. Please note, causation and aggravation are separate concepts and must be addressed independently. (Continued on the next page) The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide a reason for doing so; however, the Veteran's history of symptoms capable of lay observation cannot be dismissed solely on the basis that they are not recorded in contemporaneous treatment records. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Elias, 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.