Citation Nr: 24010641 Decision Date: 03/05/24 Archive Date: 03/05/24 DOCKET NO. 18-52 467 DATE: March 5, 2024 REMANDED Service connection for right wrist arthritis is remanded. Service connection for left wrist arthritis is remanded. Service connection for left hip arthritis with total replacement is remanded. Service connection for right hip arthritis with total replacement is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from September 1987 to December 2010. He received numerous awards and decorations to include the Combat Action Ribbon. The Board of Veterans' Appeals (the Board) previously remanded the issues on appeal for additional development in an August 10, 2022 Decision. The Department of Veteran's Affairs (VA) Regional Office (RO) having substantially complied with these remand directives, the matter again is before the Board. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268 (1998). 1. Service connection for right wrist arthritis. 2. Service connection for left wrist arthritis. 3. Service connection for left hip arthritis with total replacement. 4. Service connection for right hip arthritis with total replacement. In August 2022, the Board of Veteran's Appeals (BVA) remanded the issues on appeal for additional development. In June 2023, the Veteran attended a compensation and pension examination in order for an examiner provide a medical opinion as the etiology of the Veteran's claimed disabilities. Unfortunately, this examination was inadequate; a remand is required. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (When VA undertakes to provide a medical examination, it must be adequate). In pertinent part, in supporting rationale as to all four issues, the examiner states, "...without evidence of continuity of care there is no way to distinguish if the veteran's [claimed conditions are] related to his extensive training and combat deployments during service or from regular activities after leaving service." Unfortunately, this statement applies the wrong standard. Pursuant to 38 C.F.R. § 3.303(b), the legal standard is not continuity of care, but continuity of symptomatology. Continuous symptoms, not continuous complaints or treatment for them (i.e., care), are what VA regulations require. See Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Therefore, examiner's opinion is inadequate because the examiner impermissibly equates "chronicity of care" with "continuity of symptoms," and only the latter is required by 38 C.F.R. § 3.303(b). See Savage v. Gober, 10 Vet. App. 488, 496 (1997) (citing Wilson, 2 Vet. App. at 19). Finally, the Board notes that the Veteran has testified that his private treatment providers are surprised by some of the rating decisions that the Veteran has received. If the reason that this is the case is because the Veteran's private treatment providers are of the opinion that the Veteran's claimed disabilities are related to his active service, the Board notes that the Veteran could request that his private treatment provider author a medical nexus opinion letter. Such a letter would generally include the private treatment provider's professional credentials, the Veteran's medical history that the private treatment provider considers relevant, the provider's relevant treatment history involving the Veteran, the extent of records or scholarly works that the private treatment provider reviewed prior to forming an opinion, the provider's medical opinion as to the cause of the Veteran's disabilities and-most importantly-a supporting rationale. The matters are REMANDED for the following action: 1. Contact the Veteran and invite him to submit medical nexus letters from his treatment providers (see Reasons for Remand, above). 2. Contact the June 2023 VA examiner-or, if this individual is not available, an appropriate substitute-to provide an addendum opinion regarding the etiology of the Veteran's claimed disabilities. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation and robust rationale for all opinions expressed must be provided. The examiner must opine whether it is approximately as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's bilateral wrist and bilateral hip disabilities were incurred in or are otherwise related to his active service. The examiner is directed to consider all relevant evidence but to pay particular attention and respond to the Veteran's theory that: a) the Veteran's medical treatment providers have opined that he has early-onset moderate to severe arthritis (see letter from Dr. M.B., dated March 25, 2015), b) the Veteran has testified that his private physicians have counseled him that a man his age normally does not need joint replacements, and c) the Veteran attributes the severity of his conditions to the vigorous physical nature of his in-service activities. The examiner is reminded that medical notation of in-service treatment in the Veteran's service treatment records is not required for a grant of service connection. See Savage v. Gober, 10 Vet. App. 488, 496 (1997). Moreover, the correct criterion for providing a medical nexus opinion is continuity of symptoms-not chronicity of care. If it is not possible to provide any of the requested opinions without resorting to speculation, please 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); in the record (additional facts are required); or in your own knowledge or training. S. F. Keane Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Drum, Ryan S. 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.