Citation Nr: 22012287 Decision Date: 03/03/22 Archive Date: 03/03/22 DOCKET NO. 16-46 525 DATE: March 3, 2022 REMANDED Entitlement to a compensable rating for left eye lattice degeneration and bilateral pinguecula is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from April 2002 to April 2006. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) St. Petersburg, Florida. Jurisdiction of this appeal is currently with the RO in Roanoke, Virginia. This case was most recently before the Board in October 2021, at which time the appeal was remanded to the Agency of Original Jurisdiction (AOJ) for further development. The case has now been returned to the Board for appellate action. In addition, in a December 2021 rating decision, the AOJ granted service connection for bilateral pinguecula and consolidated with the existing rating for left eye lattice degeneration. However, for the reasons discussed below, the issue of a compensable rating for bilateral pinguecula remains before the Board. Increased Rating Left Eye Lattice Degeneration and Bilateral Pinguecula The Veteran seeks entitlement to an increased rating for his service-connected left eye lattice degeneration and bilateral pinguecula. Specific argument in support of this appeal has not been provided. The October 2021 Board remand found that additional VA examinations were warranted prior to determining the appropriate rating for the Veteran's left eye lattice degeneration and bilateral pinguecula. Specifically, the October 2021 Board remand determined that the VA opinion obtained pursuant to the Board's August 2019 remand directives established that the Veteran had bilateral pinguecula that was related to his active service; and found that the condition was within the scope of the Veteran's appeal for an increased rating for his left eye lattice degeneration. Accordingly, the October 2021 Board remand recharacterized the issue on appeal as characterized on the cover page of this decision. The October 2021 Board remand further noted that, pursuant to the August 2019 Board remand directives, the November 2019 VA examiner noted that, in addition to left eye lattice degeneration, the examiner diagnosed bilateral pinguecula. Unfortunately, the October 2021 Board remand found the November 2019 VA examination report insufficient to appropriately rate the disability. In this regard, the October 2021 Board remand noted that although pinguecula may not be considered "scarring" in the medical sense of the term; VA regulations treated them as such for the purpose of evaluating the severity of the disability. Therefore, the sizes of the Veteran's pinguecula is information that is necessary to properly adjudicate the claim. Consequently, the October 2021 Board remand found that remand was again warranted to obtain an addendum opinion concerning the etiology of the Veteran's right eye lattice degeneration; and specify and identify the types of scarring or disfigurement caused by the bilateral pinguecula, to include a measurement of the approximate size of each pinguecula, as well as individual and combined total areas for the pinguecula in both eyes. The Veteran was afforded the directed VA examination in December 2021. At that time, the VA examiner opined the Veteran's right lattice degeneration was less likely than related to service as it was not diagnosed in service. Additionally, the VA examiner opined the Veteran's right lattice degeneration was less likely than not proximately due to or the result of the Veteran's service-connected left eye because it involved the opposite eye. Regardless of an established baseline, the VA examiner opined the Veteran's right eye lattice degeneration was less likely than not aggravated beyond its natural progression by his service-connected condition because lattice degeneration of the left eye cannot influence the other eye. The December 2021 VA examiner also opined that the Veteran's pinguecula involved the anterior ocular surface of the eye and is not related at all, or able to be influenced by retinal findings, including lattice. In this regard, the VA examiner noted that the diagnoses of pinguecula and lattice degeneration of the right eye are separate and unrelated because pinguecula involves the ocular surface of the eye and lattice degeneration involves the retina or posterior part of the eye; and the lattice of the left eye is unrelated to the lattice of the right eye as it involves the opposite eye. The Board finds the December 2021 VA examination opinions inadequate to decide the claims because the examiner did not render the requested opinions in the October 2021 Board remand directives; namely, the specificity of the size and total surface area, and any impairments due to "scarring" of the bilateral pinguecula. Additionally, the VA examiner did not provide supporting rationale for the conclusions reached as to the right eye lattice degeneration, and provided only conclusory statements without further elaboration. Thus, in order to avoid additional remands and avoid the possibility of issuing another inadequate opinion, the VA examiner is requested to comply with the Board's remand directives and only issue the medical opinion specifically requested for each issue and restate the opinion utilizing the exact language specified. See Stegall v. West, 11 Vet. App. at 268, 271 (1998). Where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board regrets the additional delay, but an adequate VA examination is needed before the Board can render a decision on this issue. Given these deficiencies, the Board is unable to find that substantial compliance with the prior remand has been achieved. See D'Aries, 22 Vet. App. at 105; see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999). As such, remand is again required to obtain additional VA addendum opinions that comply with the Board's prior remand directives. See Stegall v. West, supra. The matter is REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, schedule the Veteran for an examination by an appropriate examiner to determine the current nature and severity of his service-connected bilateral pinguecula based on scarring and/or disfigurement. The record, to include a copy of this Remand, should be provided to the examiner and all indicated tests and/or studies should be conducted. The examiner should describe the nature and severity of the manifestations of the Veteran's bilateral pinguecula, to include ay resulting functional impairment. The examiner should specifically identify he types of scarring/disfigurement caused by the pinguecula, to include a measurement of the approximate size of each pinguecula, as well as individual and combined total areas for the pinguecula in both eyes. In this regard, the Board notes that while pinguecula may not be considered "scarring" or "disfigurement" in the medical sense of the terms, VA regulations treat them as such for the purpose of evaluating and rating the severity of the disability. In addition, the examiner is asked to address the following questions related to the etiology of the Veteran's right eye lattice degeneration, diagnosed during a December 2011 VA examination: (a.) Is it at least as likely as not (50/50 probability or greater) that the Veteran's right eye lattice degeneration began during or is otherwise related to her service? (b.) Is it at least as likely as not (50/50 probability or greater) that the Veteran's right eye lattice degeneration was caused or aggravated by her service-connected left eye lattice degeneration? The Board notes that causation and aggravation are independent concepts and should have separate findings and rationales. As such, the examiner must provide separate findings and rationales relating to causation and aggravation. Aggravation under 38 C.F.R. § 3.310 (b) does not require that there be "permanent" worsening of the nonservice connected disability. Ward v. Wilkie, 31 Vet. App. 233 (2019). A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). (Continued on the next page) The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resorting to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mariah N. Sim, 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.