Citation Nr: 22017127 Decision Date: 03/24/22 Archive Date: 03/24/22 DOCKET NO. 17-57 045 DATE: March 24, 2022 ORDER Entitlement to service connection for left upper extremity peripheral neuropathy, as secondary to service-connected left lateral elbow epicondylitis, is granted. REMANDED Entitlement to service connection for right upper extremity peripheral neuropathy, to include as secondary to service-connected right shoulder disability, is remanded. Entitlement to service connection for degenerative arthritis of the cervical spine, to include as secondary to service-connected bilateral shoulder disabilities, is remanded. FINDING OF FACT The competent medical evidence of record establishes that the Veteran's left upper extremity peripheral neuropathy is caused or aggravated by his service-connected left lateral elbow epicondylitis. CONCLUSION OF LAW The criteria for entitlement to service connection for left upper extremity peripheral neuropathy, as secondary to service-connected left lateral elbow epicondylitis, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Navy from October 1986 to October 1990. These matters are before the Board of Veterans' Appeals (Board) on appeal from a December 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded these matters in April 2019 for additional development. They are now returned to the Board for further appellate consideration. Entitlement to service connection for left upper extremity peripheral neuropathy The Veteran has been diagnosed with left carpal tunnel syndrome and left ulnar nerve neuropathy. He contends that his left upper extremity peripheral nerves condition is caused or aggravated by service-connected residuals of left acromioclavicular (AV) joint separation and/or left lateral elbow epicondylitis. After careful review of the evidence of record, the Board finds that service connection on a secondary basis is warranted. Service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). In March 2019, the Veteran submitted a private medical opinion prepared by G.U., a Family Nurse Practitioner., who, after review of the Veteran's entire claims file, opined that it is at least as likely as not that the Veteran's current left upper extremity ulnar neuropathy condition is secondary to, related to, and/or aggravated by his service-connected left lateral elbow epicondylitis. In an opinion incorporating current medical literature, G.U. explained that the pathophysiological mechanisms and processes that occur directly from bony and soft tissue disease at the elbow, to specifically include lateral epicondylitis and flexor muscle dysfunction, chronically compress on the ulnar nerve causing irritation of the nerve tissue leading to ulnar neuropathies or, at the very least, aggravating any existing ulnar neuropathic condition. The opinion was also accompanied by several abstracts of medical journal articles and studies, on which the clinician had highlighted the parts relevant to the Veteran's case. The Board notes that the record contains an October 2016 VA medical opinion in which a VA examiner opined that the Veteran's peripheral neuropathy is less likely than not proximately due to or the result of the Veteran's service-connected shoulder disability. The examiner reasoned that the diagnosed bilateral carpal tunnel syndrome is considered a peripheral nerve issue, mainly at the wrist, and it is less likely than not a result of any shoulder condition. In its April 2019 remand, the Board found this opinion to be inadequate as the examiner failed to provide adequate rationale for the opinion rendered. Pursuant to the Board remand, VA obtained another opinion from a VA examiner in November 2019. The examiner opined that the Veteran's peripheral neuropathy of the left upper extremity is less likely than not proximately due to or the result of the service-connected left lateral elbow epicondylitis. The rationale provided stated was only that neuropathy is an entirely separate entity from the service-connected elbow epicondylitis and that the medical literature does not support a medical relationship. The examiner then went on to explain the nature and causes of radiculopathy, which has to do with the spine. Notably, the Veteran has not been diagnosed with radiculopathy. The examiner did not address the Veteran's individual diagnoses of carpal tunnel syndrome or ulnar nerve compression. The Board finds that the November 2019 opinion is not supported by sufficient medical rationale and incorrectly identifies the Veteran's medical condition; thus, it is inadequate and afforded no probative weight. In light of the above, the Board finds the March 2019 private opinion to be the most probative evidence of record as to the issue of nexus to the Veteran's service-connected disabilities. Medical opinion evidence is probative if it includes clear conclusions and supporting data with a reasoned analysis connecting the data and conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). To that end, the Board finds the opinion has significantly greater probative weight than the VA opinions of record because it relied on medical principles and the current state of medical knowledge to explain the existence of a causal relationship between the Veteran's left upper extremity peripheral neuropathy and his service-connected left lateral elbow epicondylitis. For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether service connection for left upper extremity peripheral neuropathy is warranted. As outlined above, the probative evidence of record persuasively weighs in favor of granting service connection on a secondary basis. The benefit of the doubt doctrine, see 38U.S.C. §5107(b), is therefore not for application as to this claim. Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021), affirmed en banc 2021 U.S. App. LEXIS 37307 (Dec. 17, 2021) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). Accordingly, the Veteran's appeal is granted. REASONS FOR REMAND As to the issues remaining on appeal, the Board is not satisfied that there was substantial compliance with its most recent remand directives; therefore, the matters must be remanded once again. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for right upper extremity peripheral neuropathy, to include as secondary to service-connected right shoulder disability, is remanded. 2. Entitlement to service connection for degenerative arthritis of the cervical spine, to include as secondary to service-connected bilateral shoulder disabilities, is remanded. In its April 2019 remand, the Board directed the RO to obtain addendum medical opinions adequately addressing whether the Veteran's right upper extremity and cervical spine disabilities are caused or aggravated by the Veteran's service-connected shoulder disabilities. VA attempted to obtain an opinion in June 2019 to address the Veteran's right upper extremity peripheral neuropathy. However, the VA examiner only provided a summary of the pertinent evidence and returned the disability benefits questionnaire (DBQ) without an accompanying etiology medical opinion. With regard to the cervical spine disability, in November 2019, a VA examiner opined that the cervical spine disability is less likely than not proximately due to or the result of the service-connected bilateral shoulder disabilities, stating only that the two conditions are not medically related, are entirely separate entities, and the medical literature does not support a medical relationship. The examiner added that cervical spine arthritis is not caused or aggravated by shoulder or arm conditions, but is due to natural aging. The Board finds this opinion inadequate because it is conclusory and not supported by adequate medical rationale. Moreover, the examiner did not separately address the matter of aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). In light of the above, the Board finds that the record still does not contain medical opinions that are sufficient to fairly decide the Veteran's service connection claims for right upper extremity and cervical spine disabilities. Therefore, the claims must be remanded once again because the RO did not comply with the Board's prior remand directive to obtain adequate medical opinions on the Veteran's behalf. See Stegall, 11 Vet. App. at 271. On remand, addendum medical opinions must be obtained that are adequate for the Board to make an informed decision on the Veteran's claims. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007); Douglas v. Shinseki, 23 Vet. App. 19, 26 (2009). Accordingly, the matters are REMANDED for the following action: Forward the Veteran's claims file to a qualified VA physician (M.D.) who has not yet provided an opinion in this case to provide the requested addendum medical opinions. An in-person VA examination need not be scheduled unless deemed necessary by the examiner or otherwise required by the evidence. The examiner must review the claims file in its entirety, to include a copy of this REMAND, and that review must be noted in the report. Thereafter, the examiner is asked to provide fully-articulated medical opinions adequately addressing the following: Right Upper Extremity (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's right upper extremity carpal tunnel syndrome and/or ulnar nerve compression is caused by his service-connected right shoulder disability? (b) Is it at least as likely as not (50 percent or greater probability) that the Veteran's right upper extremity carpal tunnel syndrome and/or ulnar nerve compression is aggravated by (increased in severity beyond its natural progression) his service-connected right shoulder disability? Cervical Spine (c) Is it at least as likely as not (50 percent or greater probability) that the Veteran's cervical spine disability is caused by his service-connected right and left shoulder disabilities? (d) Is it at least as likely as not (50 percent or greater probability) that the Veteran's cervical spine disability is aggravated by (increased in severity beyond its natural progression) his service-connected right and left shoulder disabilities? Separately-articulated opinions must be provided to address causation and aggravation. In addressing the matter of aggravation, the examiner should note that it is not required that the claimed disability is shown to be aggravated beyond natural progression predominantly or permanently by the service-connected disability, but rather, whether there is any contributing degree of aggravation beyond natural progression by the service-connected disability. The examiner is reminded that the term "at least as likely as not" does not mean "within the realm of possibility." Rather, it means that the weight of the medical evidence both for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against it. The examiner is advised that the Veteran is competent to report his medical history, including the onset of symptoms, and such lay contentions in the record must be acknowledged and considered in formulating any opinion. The examiner must provide a complete rationale for any opinions offered, citing to the examiner's own expertise, medical principals, and/or evidence in the Veteran's claims file, when necessary, to support the conclusion reached. If an opinion cannot be reached without resorting to speculation, the examiner must fully explain why that is so. The Board reminds the examiner (and the RO) that failure to comply with the examination directives outlined herein will render the opinion inadequate and will result in further remand of the Veteran's claims. J. NICHOLS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Melissa Barbee, 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.