Citation Nr: 18139960 Decision Date: 10/01/18 Archive Date: 10/01/18 DOCKET NO. 13-28 999 DATE: October 1, 2018 REMANDED Entitlement to service connection for hypertension, to include as secondary to the service-connected disability of diabetes mellitus, type II, is remanded. Entitlement to service connection for erectile dysfunction (ED), to include as secondary to the service-connected disability of diabetes mellitus, type II, is remanded. Entitlement to service connection for left arm peripheral neuropathy, to include as secondary to the service-connected disability of diabetes mellitus, type II, is remanded. Entitlement to service connection for right arm peripheral neuropathy, to include as secondary to the service-connected disability of diabetes mellitus, type II, is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1969 to January 1972. A video conference hearing was held before the undersigned Veterans Law Judge (VLJ) in June 2017. A transcript of the hearing is of record. This appeal was previously before the Board in October 2017, at which time it was remanded for further development. 1. Entitlement to service connection for hypertension, to include as secondary to the service-connected disability of diabetes mellitus, type II, is remanded. 2. Entitlement to service connection for ED, to include as secondary to the service-connected disability of diabetes mellitus, type II, is remanded. 3. Entitlement to service connection for left arm peripheral neuropathy, to include as secondary to the service-connected disability of diabetes mellitus, type II, is remanded. 4. Entitlement to service connection for right arm peripheral neuropathy, to include as secondary to the service-connected disability of diabetes mellitus, type II, is remanded. The Board finds that additional development is needed prior to final adjudication of the issues on appeal. In a September 2018 Appellant’s Post-Remand Brief, the Veteran’s representative now argues that the Veteran’s obesity is an “intermediate step” between his service-connected diabetes mellitus, type II and his claimed hypertension. Although the VA does not consider obesity a disease in itself, obesity can be an “intermediate step” between a service-connected disability and a current disability if proximate causation is shown. Here, proximate causation would be established if (1) diabetes mellitus, type II caused the Veteran to become obese; (2) obesity was a substantial factor in causing hypertension; and (3) hypertension would not have occurred but for the obesity that was caused by diabetes mellitus, type II. See VAOPGCPREC 1-2017 (January 6, 2017). The Board acknowledges that this theory of entitlement was not address by the December 2017 VA opinion. Accordingly, the Board will remand to obtain a supplemental opinion. In addition, the Veteran’s representative argues that the VA examiner did not address clinical causal relationships between diabetes mellitus, type II and ED. The Board agrees, and will remand to obtain an opinion that addresses this issue and how it may apply to the facts in the Veteran’s case. Finally, in the October 2017 remand, the Board directed the AOJ to schedule the Veteran for an examination regarding the Veteran’s claimed right and left arm peripheral neuropathy. The examiner was asked to provide an opinion that addressed whether any diagnosed peripheral neuropathy of the right and left arm was caused or aggravated by his service-connected diabetes mellitus, type II. However, the examiner did not provide an opinion addressing aggravation. Accordingly, the Board will remand to obtain a new opinion. In addition, the Board asks that the examiner address the Veteran’s contentions, made at the June 2017 hearing, that he has been told by his treating physicians that his peripheral neuropathy is due to his diabetes. The Board also asks that the examiner address any medication in the Veteran’s treatment records that indicates that he is being treated for peripheral neuropathy, including Foltx and Gabapentin. The matters are REMANDED for the following action: 1. After securing any necessary consent forms from the Veteran, obtain any outstanding treatment records, to include any VA and/or private treatment records, pertaining to the issues on appeal. 2. Upon completion of the above, obtain new medical opinions to address the following. If necessary, schedule the Veteran for a new VA examination. For all examinations and opinions, all necessary development should be taken. The VA examiner should be given access to the claim file. The examiner should state that a review of the claim file was completed. (a) Obtain a new medical opinion to address the etiology of the Veteran’s hypertension. The examiner is asked to provide an opinion as to whether it is at least as likely as not that the Veteran’s hypertension was caused or aggravated by his service-connected diabetes mellitus, type II. The examiner is asked to specifically address the Veteran’s claimed obesity, and his claim that his obesity is an “intermediate step” between his service-connected diabetes mellitus, type II and his hypertension. Although the VA does not consider obesity a disease in itself, obesity can be an “intermediate step” between a service-connected disability and a current disability if proximate causation is shown. The examiner is asked to provide an opinion, which addresses: (1) whether the Veteran’s diabetes mellitus, type II caused the Veteran to become obese; (2) whether the Veteran’s obesity was a substantial factor in causing hypertension; and (3) whether the Veteran’s hypertension would not have occurred but for the obesity that was caused by diabetes mellitus, type II. (b) Obtain a new medical opinion to address the etiology of the Veteran’s ED. The examiner is asked to provide an opinion whether it is at least as likely as not that the Veteran’s ED was caused or aggravated by his service-connected diabetes mellitus, type II. The examiner is asked to specifically address clinical causal relationships between diabetes mellitus, type II and ED, and how this may apply to the Veteran in this case. (c) Obtain a new medical opinion to address the etiology of the Veteran’s claimed right and left arm peripheral neuropathy. The examiner is asked to provide an opinion whether it is at least as likely as not that the Veteran’s claimed right and left arm peripheral neuropathy, or diagnosed carpal tunnel syndrome (left), were caused or aggravated by his service-connected diabetes mellitus, type II. In addition, the examiner is asked to address the Veteran’s contentions, made at the June 2017 hearing, that he has been told by his treating physicians that his peripheral neuropathy is due to his diabetes. The examiner should also address any medication listed in the Veteran’s treatment records that indicates that he is being treated for peripheral neuropathy, including Foltx and Gabapentin. For all opinions, the examiner(s) must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. A detailed rationale is requested for all opinions provided. CONTINUED ON NEXT PAGE 3. If upon completion of the above action the issues are denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Foster, Associate Counsel