Citation Nr: 23006802 Decision Date: 02/02/23 Archive Date: 02/02/23 DOCKET NO. 18-26 102 DATE: February 2, 2023 REMANDED Entitlement to service connection for lumbar radiculopathy left lower extremity is remanded. Entitlement to service connection for lumbar radiculopathy right lower extremity is remanded. Entitlement to service connection for cervical neuropathy right upper extremity is remanded. Entitlement to service connection for cervical neuropathy left upper extremity is remanded. Entitlement to service connection for dizziness is remanded. Entitlement to service connection for fatigue is remanded. Entitlement to service connection for palpitations is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1995 to September 2015. These matters come to the Board of Veterans' Appeals (Board) on appeal from a February 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran originally requested a Board hearing in his May 2018 VA Form 9, Appeal to Board of Veterans' Appeals. The Veteran withdrew his request for a Board hearing in February 2021. 1. Entitlement to service connection for lumbar radiculopathy left lower extremity is remanded. 2. Entitlement to service connection for lumbar radiculopathy right lower extremity is remanded. 3. Entitlement to service connection for cervical neuropathy right upper extremity is remanded. 4. Entitlement to service connection for cervical neuropathy left upper extremity is remanded. 5. Entitlement to service connection for dizziness is remanded. 6. Entitlement to service connection for fatigue is remanded. 7. Entitlement to service connection for palpitations is remanded. The Board is unable to make a fully informed decision on the issue of entitlement to service connection for bilateral lower extremity radiculopathy, bilateral upper extremity neuropathy, dizziness, fatigue and palpitations. In the rating decision on appeal and in the April 2018 statement of the case (SOC), the issues of entitlement to service connection for bilateral lower extremity radiculopathy, bilateral upper extremity neuropathy, dizziness, fatigue, and palpitations were denied because the evidence did not show current diagnosed disabilities. However, VA treatment records added to the claims file in March 2017 and April 2018, prior to issuance of the SOC, demonstrate diagnoses and treatment of ulnar neuropathy, chronic fatigue syndrome, and tachycardia. Further, in Section 1 of the June 2015 peripheral nerves examination report, the examiner determined that the Veteran does not have a peripheral nerve condition or peripheral neuropathy. Yet, the examiner remarked that it is acknowledged the Veteran may have occasional flare ups of tingling sensation and numbness to the upper extremities as well as lower extremity radiculopathy; however, there is insignificant evidence to render a diagnosis today because there are no objective findings on physical exam today. The examiner further went on to note the Veteran's symptoms of radiculopathy included moderate intermittent pain, moderate tingling, and moderate numbness in his bilateral lower extremities in Section 3. As it relates to the dizziness, the June 2015 examination report is also internally inconsistent. The examiner initially indicated in Section 1 that the Veteran does not now have and has not ever been diagnosed with an ear or peripheral vestibular condition. Later, in Section 3, the examiner answers in the affirmative to the question whether the Veteran has any of the following findings, signs or symptoms attributable to Meniere's syndrome, a peripheral vestibular condition or another diagnosed condition from Section 1. The examiner identifies tinnitus, vertigo, staggering, and bilateral hearing loss. In light of the above, the Board finds that the June 2015 examinations are inadequate for adjudication purposes and remand for new examinations is warranted. The matters are REMANDED for the following action: 1. Schedule the Veteran for a new examination with the appropriate clinician to determine the nature and etiology of any bilateral lower extremity radiculopathy and bilateral upper extremity neuropathy. The examiner should review the claims file and address the following: (a.) Whether it is at least as likely as not (an approximate balance of positive and negative evidence, i.e., nearly equal probability) that the Veteran has a diagnosis of bilateral lower extremity radiculopathy or bilateral upper extremity neuropathy that (1) manifested during active service or is otherwise related to an in-service injury, event, or disease, or (2) manifested within one year after discharge from service. (b.) Whether it is at least as likely as not (an approximate balance of positive and negative evidence, i.e., nearly equal probability) that the Veteran has a diagnosis of bilateral lower extremity radiculopathy or bilateral upper extremity neuropathy that was proximately caused or aggravated by a service-connected disability. 2. Schedule the Veteran for new examinations with the appropriate clinician(s) to determine the nature and etiology of any dizziness, fatigue, and palpitations. The examiner(s) should review the claims file and address the following: (a.) Whether it is at least as likely as not (an approximate balance of positive and negative evidence, i.e., nearly equal probability) that the Veteran has a diagnosis related to dizziness, fatigue, or palpitations that was incurred during or is otherwise related to related to an in-service injury, event, or disease. ALL EXAMINERS: A rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. The Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptoms and history, he or she must provide a reason for doing so. The examiner is reminded that the lack of medical evidence is not an adequate reason for discounting the Veteran's statements. K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. B. Jackson, 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.