Citation Nr: 22016902 Decision Date: 03/23/22 Archive Date: 03/23/22 DOCKET NO. 18-37 290 DATE: March 23, 2022 REMANDED Entitlement to service connection for residuals of a left ankle sprain is remanded. Entitlement to service connection for residuals of a right wrist fracture, to include disabilities of the right hand, right fingers, and right wrist, is remanded. Entitlement to an initial compensable disability rating for residuals of central corneal scars of the right eye is remanded. REASONS FOR REMAND The Veteran had active military service from May 1955 to May 1959. These issues are on appeal from February 2016 and March 2016 rating decisions. In January 2022, the Veteran testified before the undersigned at a Board of Veterans' Appeals (Board) hearing. 1. Entitlement to service connection for residuals of a left ankle sprain is remanded. Regarding the claim of entitlement to service connection for residuals of a left ankle sprain, the Veteran submitted a timely November 2016 notice of disagreement with a February 2016 rating decision, but a Statement of the Case (SOC) has not yet been issued. A remand is required for the Agency of Original Jurisdiction (AOJ) to issue a SOC. 38 C.F.R. § 20.200; Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). 2. Entitlement to service connection for residuals of a right wrist fracture, to include disabilities of the right hand, right fingers, and right wrist, is remanded. The Board cannot make a fully-informed decision on the right wrist issue because no VA examiner has opined whether the Veteran's current diagnoses of degenerative joint disease of the right wrist and right wrist tendon (see November 2015 Hand and Finger Disability Benefits Questionnaire) are related to his active military service, to include the February 1959 fracture. The February 2016 medical opinions only addressed the Veteran's current diagnosis of right fracture of the third metacarpal. Also, the February 2016 VA examiner did not address the Veteran's statements of continuity of symptomatology since his in-service fracture (see Board hearing). Upon remand, another VA medical opinion must be obtained. 3. Entitlement to an initial compensable disability rating for residuals of central corneal scars of the right eye is remanded. In a November 2015 statement, the Veteran identified relevant outstanding private treatment records from his current optometrist. The AOJ has not made any attempts to obtain these records. A remand is required to allow VA to obtain authorization and request these records. Also, at his Board hearing, the Veteran testified that he now experiences blurry vision of the right eye. This symptom was not documented at the most recent VA eye examination in March 2016 and suggests that his service-connected right eye disability has increased in severity since he was last examined by VA. The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his residuals of central corneal scars of the right eye. Also, to date, a secondary service connection opinion has not been provided regarding the currently diagnosed cataracts and pseudophakia and the service-connected residuals of central corneal scars of the right eye. This opinion must also be obtained upon remand. The matters are REMANDED for the following actions: 1. Send the Veteran and his representative a SOC that addresses the issue of entitlement to service connection for residuals of a left ankle sprain. If the Veteran perfects an appeal by submitting a timely VA Form 9, the issue should be returned to the Board for further appellate consideration. 2. Ask the Veteran to complete a VA Form 21-4142 for Dr. Estrovich with Metropolitan Health. Make two requests for the authorized records from Dr. Estrovich, unless it is clear after the first request that a second request would be futile. 3. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's right wrist disability. The examiner must review the claims file. The examiner is also asked to provide a response to the following: (a) Is it at least as likely as not that the degenerative joint disease of the right wrist (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? (b) Is the right wrist tendon at least as likely as not related to service, including the February 1959 fracture? (c) Is the right fracture of the third metacarpal at least as likely as not related to service, including the February 1959 fracture? (d) Is the degenerative joint disease of the right wrist at least as likely as not related to service, including the February 1959 fracture? In providing the requested opinions, consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? Provide a rationale to support the opinions. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected residuals of central corneal scars of the right eye. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The examiner must review the claims file. The examiner is also asked to provide a response to the following: (a) Is the currently diagnosed cataracts of the right eye at least as likely as not proximately due to the service-connected residuals of central corneal scars of the right eye? (b) Is the currently diagnosed cataracts of the right eye at least as likely as not aggravated, i.e., worsened beyond its natural progression, by the service-connected residuals of central corneal scars of the right eye? (c) Is the currently diagnosed pseudophakia of the right eye at least as likely as not proximately due to the service-connected residuals of central corneal scars of the right eye? (d) Is the currently diagnosed pseudophakia of the right eye at least as likely as not aggravated, i.e., worsened beyond its natural progression, by the service-connected residuals of central corneal scars of the right eye? Provide a rationale to support the opinions. 5. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. If the benefits sought are not granted to the Veteran's satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. JENNIFER HWA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. M. Watkins, 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.