Citation Nr: 23015396 Decision Date: 03/14/23 Archive Date: 03/14/23 DOCKET NO. 18-46 012A DATE: March 14, 2023 REMANDED Entitlement to service connection for left upper extremity peripheral neuropathy (to include tremors and carpel tunnel syndrome) is remanded. Entitlement to service connection for right upper extremity peripheral neuropathy (to include tremors and carpel tunnel syndrome) is remanded. Entitlement to service connection for left lower extremity peripheral neuropathy (to include tremors) is remanded. Entitlement to service connection for right lower extremity peripheral neuropathy (to include tremors) is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1965 to November 1967, with confirmed service in the Republic of Vietnam from May 1966 to May 1967. It is conceded that the Veteran was exposed to herbicide agents during his Republic of Vietnam service. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2016 rating decision issued by a Regional Office (RO) of the United States Department of Veterans Affairs (VA). The Veteran provided sworn testimony before the undersigned Veterans Law Judge at a February 2022 Board hearing. A copy of the hearing transcript is complete and has been associated with the electronic claims file. These matters were previously before the Board in May 2022, where they were remanded for further evidentiary development, to include obtaining updated VA treatment records, obtaining the Veteran's private treatment records from Clemson University, and scheduling the Veteran for a VA neurological examination with accompanying medical opinions. In August 2022, the RO contacted the Veteran and requested that he authorize VA to obtain his private treatment records from Clemson University. In September 2022, the Veteran indicated that he would submit the requested private treatment records. He submitted April 2019 treatment records from chiropractor, JAW. The Veteran did not authorize VA to obtain his records from Clemson University. The Veteran's updated VA treatment records were associated with the electronic claims file in August 2022. There has been substantial compliance regarding the procurement of the Veteran's updated VA treatment records and the Veteran did not authorize VA to obtain his Clemson University private treatment records. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In November 2022, the Veteran attended a VA neurological examination; however, the Board's review of the accompanying medical opinions reveals that they are insufficient to resolve the Veteran's appeals, and the matters must be remanded for corrective action as discussed below. In the May 2022 Board decision, the VA examiner was directed to clarify whether the Veteran has been validly diagnosed with bilateral upper and lower extremity peripheral neuropathy and/or bilateral carpel tunnel syndrome during the appellate period. The VA examiner conducted an in-person physical examination and confirmed the presence of bilateral upper and lower extremity peripheral neuropathy. The VA examiner also diagnosed the Veteran with bilateral carpel tunnel syndrome within the appellate period. The VA examiner explained that the March 2016 nerve conduction studies did not indicate issues with left or right carpel tunnel syndrome, but the test was limited to identifying large fiber neuropathy as opposed to small fiber neuropathy. As the November 2022 VA examiner's statements and diagnoses are fully favorable to the Veteran, the issue of a current disability has been resolved, and the Board concludes that the Veteran has been diagnosed with bilateral upper and lower extremity peripheral neuropathy and bilateral carpel tunnel syndrome during the appellate period. The VA examiner was asked to comment on whether these disabilities were etiologically related to the Veteran's in-service exposure to herbicide agents. The VA examiner issued negative medical opinions. With regard to the Veteran's bilateral carpel tunnel syndrome and bilateral upper extremity peripheral neuropathy, the examiner stated there was not enough evidence to relate the Veteran's conditions to his herbicide agent exposure, and the conditions were more related to his history of two cerebral infarcts and his cervical spine issues, to include his cervical lordosis and his small disc protrusion at C3-5. Similarly, regarding his bilateral lower extremity peripheral neuropathy, the examiner stated there was not enough evidence to relate the Veteran's conditions to his herbicide agent exposure, and the conditions were more related to his history of two cerebral infarcts. The Board finds these medical opinions to be insufficient for adjudicative purposes as they are wholly conclusory and unsupported by cogent rationales. See Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) ("[A] mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to a doctor's opinion."); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (stating that the probative value of a medical opinion comes from the "factually accurate, fully articulated, sound reasoning for the conclusion..."). The examiner did not explain why the Veteran's disabilities were more likely related to the Veteran's two cerebral infarcts and/or his cervical spine issues than his conceded in-service exposure to herbicide agents. Accordingly, the claims must be remanded for addendum opinions that are adequately supported by thorough explanatory rationales. In the May 2022 Board decision, the VA examiner was also requested to clarify whether the Veteran suffered from Parkinson's disease during the appellate period, as this condition is eligible for presumptive service connection under the herbicide agent regulations set forth in 38 C.F.R. §§ 3.307(a)(6) and 3.309(e). The VA examiner's opinion on this matter is confusing and warrants clarification. At first, the VA examiner stated that the Veteran did not suffer from Parkinson's disease, as multiple examinations "express mild extrapyramidal findings and predominantly action." The VA examiner did not explain why this information was medically significant and weighed against a diagnosis of Parkinson's disease. Then, in the next sentence of the opinion, the VA examiner stated that "the Veteran's Parkinson's disease during the appellate period...[is not] etiologically related to the Veterans in service exposure to herbicide agent." Although unsupported by an explanatory rationale, at face value, this statement seemed to imply that the Veteran actually had Parkinson's disease. The VA examiner's medical opinion was contradictory and internally inconsistent. Accordingly, the matter is remanded for an addendum opinion that clearly explains whether the Veteran has suffered from Parkinson's disease within the appellate period. In the May 2022 decision, the Board also sought clarification on whether the Veteran's essential tremors qualified as Parkinsonism, which is a disability eligible for presumptive service connection under the herbicide agent laws, and if not, whether the Veteran's essential tremors were otherwise etiologically related to his in-service herbicide agent exposure. See 38 U.S.C. § 1116(a)(2). When prompted whether the Veteran's essential tremors were a form of Parkinsonism, the VA examiner responded, "the Veteran's tremors do not qualify as a form of Parkinson's." This statement was conclusory and unaccompanied by an explanatory rationale, and it is unclear whether the VA examiner was referencing Parkinsonism or Parkinson's disease. See Stefl, 21 Vet. App. at 125 ; Nieves-Rodriguez, 22 Vet. App. at 304. The VA examiner then issued a negative nexus opinion stating that the Veteran's essential tremors were more likely related to his history of two cerebral infarcts and his cervical spine issues than his in-service herbicide agent exposure. The examiner stated that cerebral infarcts and cervical spine issues "can cause nerve issues and/or muscle weakness to the upper extremities as the tremors are not at rest, but with action/activity." The VA examiner did not adequately explain the significance of this finding or why it weighed against in-service herbicide agent exposure as the cause of the Veteran's essential tremors. The matter must be remanded for addendum opinions that more thoroughly address the questions posed by the Board, with complete supporting rationales. Lastly, in the event that the Veteran has continued to obtain VA treatment, the RO is requested to associate any updated VA treatment records from February 2020 to the present with the electronic claims file. 38 C.F.R. § 3.159(c)(2) and (3). The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from February 2020 to the present. 2. Obtain addendum VA medical opinions from a qualified VA examiner regarding the etiology of the Veteran's neurological disabilities. Following a complete review of the electronic claims file, including a copy of this REMAND, the VA examiner is requested to address the following inquiries: (a.) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's bilateral upper and lower extremity peripheral neuropathy and bilateral carpel tunnel syndrome are etiologically related to his in-service exposure to herbicide agents? Why or why not? (b.) Since June 2015, has the Veteran been validly diagnosed with Parkinson's disease? Why or why not? (c.) Do the Veteran's essential tremors qualify as a form of Parkinsonism? Why or why not? (d.) If the Veteran's essential tremors DO NOT qualify as a form of Parkinsonism, is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's essential tremors are etiologically related to his in-service herbicide agent exposure? Why or why not? All medical opinions must be supported by complete explanatory rationales based on the VA examiner's medical expertise; the VA examiner's clinical experience; current medical principles; and citations to the record, as appropriate. If the examiner fails to support his/her opinions with thorough and complete explanatory rationales, the reports shall be returned to the examiner for corrective action. Cynthia M. Bruce Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Galante, 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.