Citation Nr: 18139897 Decision Date: 10/01/18 Archive Date: 10/01/18 DOCKET NO. 16-05 859 DATE: October 1, 2018 ORDER Entitlement to service connection for peripheral neuropathy of the bilateral upper extremities, as secondary to the Veteran’s service connected diabetes mellitus type II, is granted. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities, as secondary to the Veteran’s service connected diabetes mellitus type II, is granted. Entitlement to an increased rating not exceeding 30 percent for the Veteran’s ischemic heart disease (coronary artery disease status post drug eluting stent placement or the “heart condition”) is granted at this time (a possible higher rating than this will be addressed below). REMANDED Entitlement to an increased rating exceeding 30 percent for the Veteran’s ischemic heart disease (coronary artery disease status post drug eluting stent placement) is remanded. FINDINGS OF FACT 1. The Veteran’s peripheral neuropathy of the bilateral upper extremities is proximately due to his service-connected diabetes mellitus type II. 2. The Veteran’s peripheral neuropathy of the bilateral lower extremities is proximately due to his service-connected diabetes mellitus type II. 3. At this time, the evidence of record reasonably shows that the Veteran’s ischemic heart disease (coronary artery disease status post drug eluting stent placement) presents evidence of cardiac hypertrophy on an echocardiogram. CONCLUSIONS OF LAW 1. The criteria for secondary service connection for peripheral neuropathy of the bilateral upper extremities are met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). 2. The criteria for secondary service connection for peripheral neuropathy of the bilateral lower extremities are met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). 3. The criteria for an initial increase rating not exceeding 30 percent for the Veteran’s ischemic heart disease (coronary artery disease status post drug eluting stent placement) have been met. 38 U.S.C. §§ 7105(b)(2), 7105(d)(5); 38 C.F.R. § 4.104, Diagnostic Code 7005. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1968 to January 1970, with service in Vietnam where he received the Bronze Star and Purple Heart. The Veteran appeals September 2011 and January 2017 rating decisions from the Department of Veteran Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The Veteran had his video Board hearing in May 2018. A transcript is associated with the file. Service Connection The Veteran asserts that his peripheral neuropathy in bilateral upper and lower extremities is caused, or aggravated beyond natural progression, by his service connected diabetes mellitus type 2. Service connection is warranted where the evidence of record establishes that a particular injury or disease results in a present disability that incurred in the line of duty during active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310(a). Secondary service connection may also be granted for aggravation of a disease or injury by a service-connected disability. Id. To establish secondary service connection based on aggravation, the evidence must show an increase in severity of a disease or injury beyond a medically established baseline that is proximately due to or the result of a service-connected disease or injury and not due to the natural progress of the nonservice-connected condition. 38 C.F.R. § 3.310(b). The Veteran was diagnosed with peripheral polyneuropathy of the upper and lower extremities in 2005. The Veteran is currently service connected for diabetes mellitus type II due to Agent Orange exposure. Thus, the claim turns on whether the Veteran’s peripheral neuropathy is either proximately due to, or aggravated beyond its natural progress by the Veteran’s diabetes mellitus type II. The Veteran was afforded a VA exam in August 2015. The August 2015 VA examiner stated that the Veteran did not have symptoms of diabetic neuropathy. An August 2016 private physician’s note stated that the Veteran suffers from “Type 2 Diabetes Mellitus, which was diagnosed in 2005, with resultant peripheral polyneuropathy of the upper and lower extremities.” Further, an August 2016 VA medical treatment note found the Veteran had type II diabetes with secondary peripheral neuropathy. The August 2016 VA medical treatment note reported that the Veteran’s peripheral neuropathy affected his hands and feet. The Veteran was afforded another VA examination in January 2017. The January 2017 VA examiner stated it would be speculative that the Veteran’s pre-existing peripheral neuropathy of the bilateral upper and lower extremities was aggravated beyond normal progression due to diabetes mellitus type II. In sum, the Board acknowledges the differing opinions proffered by two equally qualified medical professionals and concludes that one opinion does not outweigh the other. The Board thus finds that the record evidence is at least in relative equipoise as to whether the Veteran’s peripheral neuropathy of the bilateral upper and lower extremities was caused by diabetes mellitus type II. The Board notes that when the evidence is in relative equipoise, by law; the Board must resolve all reasonable doubt in favor of the claimant. See U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinksi, 1 Vet. App. 49, 53-56 (1990). Therefore, the Board finds that service connection for peripheral neuropathy for the bilateral upper and lower extremities secondary to diabetes mellitus type II is warranted. Increased Rating The Veteran asserts that he is entitled to an initial rating in excess of 10 percent for the Veteran’s ischemic heart disease (coronary artery disease status post drug eluting stent placement). At this time, the Veteran is at 10% for this rating. Disability evaluations are determined by comparing the Veteran’s present symptomatology with the criteria set forth in the VA’s Schedule for Ratings Disabilities. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. Higher ratings are assigned if the disability more nearly approximates the criteria for that rating; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence the benefit of the doubt is to be resolved in the Veteran's favor. 38 U.S.C. § 5107(b). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings,” whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the Board does not find staged ratings necessary. Under Diagnostic Code 7005, arteriosclerotic heart disease (coronary artery disease (CAD)) provides a 10 percent rating when documented CAD produces dyspnea, fatigue, angina, dizziness, or syncope with a workload of greater than 7 METs but not greater than 10 METs, or when continuous medication is required. 38 C.F.R. § 4.104, DC 7005. A 30 percent rating is assigned when a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. Id. A 60 percent rating is assigned for more than one episode of acute congestive heart failure in the past year, or; when a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; for left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Id. A 100 percent rating is assigned for chronic congestive heart failure, or; when a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; for left ventricular dysfunction with an ejection fraction of less than 30 percent. Id. In February and July 2011 VA medical treatment notes, the Veteran had left ventricular ejection fraction (LVEF) readings of 60, 74, and 65-70 percent. The Veteran underwent a VA examination in July 2011. The VA examiner noted that the Veteran required continuous medication. The Veteran’s LVEF reading was 65-70 percent. The Veteran was not able to complete an exercise stress test due to the Veteran’s peripheral neuropathy. Through an interview with the Veteran, the VA examiner opined that the Veteran had a 3-5 MET score with dyspnea and fatigue. The VA examiner opined that the LVEF reading is a better indicator of his heart functioning because the MET is limited due to the “co-morbid medical condition of bilateral lower extremity neuropathy.” Private medical notes from late 2011 found the Veteran had LVEF readings of 50-55, and 55-60 percent. September 2013 and 2015 private medical notes found the Veteran had LVEF readings of 71 and 70 respectively. The Veteran was afforded a VA examination in December 2015. The VA examiner reported that the Veteran does not have congestive heart failure, cardiac arrhythmia, or a valve condition. The LVEF reading was 60 to 65 percent. The VA examiner opined that there was evidence of cardiac hypertrophy on an echocardiogram. The Veteran did not present evidence of cardiac dilation. The Veteran had 1-3 METs with fatigue and dyspnea based on an interview with the VA examiner. However, the VA examiner opined, similarly to the July 2011 VA exam, that the Veteran’s METs were of limited use because it was impossible to estimate the percentage of MET limits attributable to either CAD or peripheral neuropathy. Thus, the VA examiner reported that the LVEF reading was a better indicator of the Veteran’s heart functioning. Based on the above, the Board finds that a rating no greater than 30 percent is warranted at this time. During the Veteran’s December 2015 VA examination, an echocardiogram found evidence of cardiac hypertrophy. As such, we find a 30 percent rating is warranted. As outlined above, the Veteran’s LVEF readings range from 50 to 74. Based on LVEF readings, an increased rating of 100 and 60 percent is not warranted. We do note that the Veteran’s MET scores, 3-5 in the July 2011 VA exam and 1-3 in the December 2015 VA exam. However, the VA examiners both stated that the Veteran’s CAD and peripheral neuropathy made it difficult to attribute a specific limitation percentage to either condition. Therefore, an increased rating of 100 and 60 percent is not warranted at this time. Consequently, a rating greater than 30 percent for the Veteran’s ischemic heart disease (coronary artery disease status post drug eluting stent placement) is unwarranted. It is important for the Veteran to understand that a 30 percent disability for a heart condition will cause the Veteran many problems. The only question is the degree of the problem based on the criteria above. Finally, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record with regards to these claims. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming the Board is not required to address issues raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND As noted above, the Board finds a basis for a 30% evaluation for the heart condition at this time, based on this evidence. There may be a basis for a higher evaluation for this condition, but more development is needed. The issue of entitlement to an increased rating in excess of 30 percent is remanded for further development. The Veteran had a December 2015 VA examination for his heart condition. In the December 2015 VA examination, the VA examiner stated that the Veteran had no other hospitalizations besides a 2011 stent operation in the Toledo Hospital. The Veteran stated in his May 2018 Board hearing that he had four hospitalizations for his heart condition. For example, an August 2015 VA medical note reported the Veteran had a hospitalization to correct a stent failure. Therefore, a new VA examination is warranted to fully address this issue. The matter is REMANDED for the following action: 1. Obtain and associate with the record all VA treatment records for the Veteran. All actions to obtain the requested records should be fully documented in the record. If they cannot be located or no such records exist, the Veteran and his representative should be so notified in writing. If possible, the Veteran and his representative are asked to submit these records themselves. 2. Schedule the Veteran for a new VA heart examination. The claims file and a copy of this remand must be made available to and reviewed by the examiner in conjunction with the examination. All pertinent symptomatology and findings must be reported in detail in accordance with VA rating criteria per Diagnostic Code 7005. The examiner should provide, to the greatest extent possible, comprehensive information that addresses all components of the applicable rating criteria, to include an assessment of exercise capacity in terms of METs (metabolic equivalent); left ventricular function; any evidence of congestive heart failure; and any associated symptoms including dyspnea, fatigue, angina, dizziness, or syncope, and its frequency. If the examiner is unable to obtain reliable METs results, he or she must clearly explain why this is so. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should also address the functional effects of the Veteran's disability on his ability to secure or follow a substantially gainful occupation. 3. After completing the aforementioned, and any further development deemed necessary, adjudicate the Veteran’s claim. If the benefit sought on appeal is not granted in full, the Veteran and his representative should be furnished with a Supplemental Statement of the Case and afforded an opportunity to respond before the file is returned to the Board for further appellate consideration. JOHN J. CROWLEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Timothy A. Campbell, Associate Counsel