Citation Nr: 18153215 Decision Date: 11/28/18 Archive Date: 11/27/18 DOCKET NO. 16-39 076 DATE: November 28, 2018 ORDER Entitlement to service connection for left foot hammer toes is denied. Entitlement to service connection for right foot hammer toes is denied. Entitlement to service connection for obstructive sleep apnea is granted. Entitlement to service connection for ischemic heart disease is denied. Entitlement to service connection for amyloidosis is denied. Entitlement to service connection for an acquired psychiatric disability, diagnosed as depressive disorder with anxious features, is granted. Entitlement to an evaluation in excess of 20 percent for diabetes mellitus with erectile dysfunction and renal insufficiency is denied. Entitlement to a 40 percent evaluation, but no higher, for urinary frequency associated with service-connected diabetes mellitus is granted. Entitlement to a 40 percent evaluation, but no higher, for left lower extremity peripheral neuropathy is granted. Entitlement to a 40 percent evaluation, but no higher, for right lower extremity peripheral neuropathy is granted. REMANDED Entitlement to service connection for peripheral vascular disease is remanded. Entitlement to service connection for breast cancer is remanded. Entitlement to service connection for a neurological condition is remanded. FINDINGS OF FACT 1. The evidence is against a finding that the Veteran has a current disability manifested by left foot hammer toes. 2. The evidence is against a finding that the Veteran has a current disability manifested by right foot hammer toes. 3. The Veteran’s obstructive sleep apnea is aggravated by his service-connected depressive disorder with anxious features. 4. The evidence is against a finding that the Veteran has a current disability manifested by ischemic heart disease and a diagnosed heart condition has not been attributed to service. 5. The evidence is against a finding that the Veteran has a current disability manifested by amyloidosis. 6. The Veteran’s acquired psychiatric disability, diagnosed as depressive disorder with anxious features, is caused by service-connected diabetes mellitus and bilateral lower extremity peripheral neuropathy. 7. The Veteran’s service-connected diabetes mellitus is managed by restricted diet and oral medication, but does not require insulin or restriction of activities. 8. The Veteran’s urinary frequency associated with service-connected diabetes mellitus has caused a daytime voiding interval of approximately one hour and nighttime awakening to void five or more times. 9. The Veteran’s service-connected left lower extremity peripheral neuropathy has been manifested by moderately severe incomplete paralysis. 10. The Veteran’s service-connected right lower extremity peripheral neuropathy has been manifested by moderately severe incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for service connection for left foot hammer toes have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 2. The criteria for service connection for right foot hammer toes have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 3. The criteria for service connection for obstructive sleep apnea have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). 4. The criteria for service connection for ischemic heart disease have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 5. The criteria for service connection for amyloidosis have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 6. The criteria for service connection for an acquired psychiatric disability, diagnosed as depressive disorder with anxious features, have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). 7. The criteria for an evaluation in excess of 20 percent for service-connected diabetes mellitus with erectile dysfunction and renal insufficiency have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.120, Diagnostic Code 7913 (2017). 8. The criteria for a 40 percent evaluation, but no higher, for urinary frequency associated with service-connected diabetes mellitus have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.115a, Diagnostic Code 7541 (2017). 9. The criteria for a 40 percent evaluation, but no higher, for service-connected left lower extremity peripheral neuropathy have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.124a, Diagnostic Code 8520 (2017). 10. The criteria for a 40 percent evaluation, but no higher, for service connected right lower extremity peripheral neuropathy have been met. 38 U.S.C. 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.124a, Diagnostic Code 8520 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1969 to May 1971. The Veteran’s claims for service connection for depression and anxiety have been broadened to an acquired psychiatric disability. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Service Connection A Veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in the line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty in active service. 38 U.S.C. §§ 1110, 1131. Generally, to establish a right to compensation for a present disability, a veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that a disease was incurred in service. 38 C.F.R. § 3.303(d). Under section 3.310(a) of VA regulations, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show: (1) a current disability; (2) a service-connected disability; and (3) a nexus between the current disability and the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1988). As to the third Wallin element, the current disability may be either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). 1. Bilateral hammer toes The Veteran filed a March 2015 claim for service connection for left foot and right foot hammer toes. See March 2015 VA Form 21-526EZ. The Veteran’s service treatment records do not support any treatment, diagnoses, or reports of hammer toes. Further, an April 1971 report of medical examination at service separation indicated the Veteran had normal feet and lower extremities. Post-service treatment records are also negative for treatment, diagnoses, or reports of hammer toes. Significantly, September 2012 and October 2013 VA foot examinations revealed normal visual inspection, normal pedal pulses, no deformity (including presence of Charcot, severe, hammertoe, and bunion deformity), and normal skin between toes. See September 2012 and October 2013 VA primary care notes. Although the Veteran believes that he has current a left foot and right foot hammer toes disability that is attributable to service, he is not competent to provide a diagnosis in this case. These issues are medically complex, and require specialized medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence, which demonstrates that the Veteran does not have diagnosed left foot and right foot hammer toes. Accordingly, service connection for left foot and right foot hammer toes must be denied. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Therefore, the Board finds that the preponderance of the evidence is against the claims for service connection for left foot hammer toe and right foot hammer toe, and that the claims must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. An acquired psychiatric disability, diagnosed as depressive disorder with anxious features The Veteran filed December 2014 claims for service connection for anxiety and depression. See December 2014 VA Form 21-526EZ. The first and second Wallin elements are met and not in dispute. In a December 2016 private psychologist’s disability benefits questionnaire (DBQ), Dr. R.W. diagnosed the Veteran with depressive disorder with anxious features. Further, the Veteran is service-connected for diabetes mellitus and bilateral lower extremity peripheral neuropathy. As such, the crux of this case centers on whether there is an etiological relationship between the Veteran’s depressive disorder with anxious features and his service-connected diabetes mellitus and bilateral lower extremity peripheral neuropathy. The August 2016 VA examiner opined that the Veteran’s unspecified depressive disorder is less likely than not (less than 50 percent probability) in or caused by the claimed in-service injury, event, or illness. The basis for the examiner’s opinion was that review of the record showed the Veteran was first diagnosed with unspecified depressive disorder in July 2015. However, Dr. R.W. opined that the Veteran’s depressive disorder with anxious features is more likely than not caused by his service-connected diabetes mellitus and bilateral lower extremity peripheral neuropathy. See December 2016 private psychologist’s DBQ. Affording the Veteran the benefit of reasonable doubt, the Board finds there is competent and credible medical evidence of record establishing a link between the Veteran’s depressive disorder with anxious features and his service-connected diabetes mellitus and bilateral lower extremity peripheral neuropathy. Accordingly, the Board grants service connection for an acquired psychiatric disability, diagnosed as depressive disorder with anxious features. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 3. Obstructive sleep apnea The Veteran filed a December 2014 claim for service connection for sleep apnea. See December 2014 VA Form 21-526EZ. The first and second Wallin elements are met and not in dispute. In a December 2016 private DBQ, Dr. H.S. diagnosed the Veteran with obstructive sleep apnea. See December 2016 private DBQ. Further, pursuant to the above, the Veteran is service-connected for depressive disorder with anxious features. As such, the crux of this case centers on whether there is an etiological relationship between the Veteran’s obstructive sleep apnea and his service-connected depressive disorder with anxious features. Dr. H.S. opined that the Veteran’s depressive disorder permanently aggravated his obstructive sleep apnea. Affording the Veteran the benefit of reasonable doubt, the Board finds there is competent and credible medical evidence of record establishing a link between the Veteran’s obstructive sleep apnea and his service-connected depressive disorder with anxious features. Accordingly, the Board grants service connection for obstructive sleep apnea. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 4. Entitlement to service connection for ischemic heart disease The Veteran filed a March 2015 claim for service connection for ischemic heart disease. See March 2015 VA Form 21-526EZ. As an initial matter, the Board notes that the Veteran had combat service in Vietnam and herbicide exposure has been conceded. See August 2010 rating decision and Form DD-214. The Veteran was afforded an August 2016 VA heart conditions examination and the report indicated that the Veteran had diagnosed heart block and hypertensive heart disease diagnosed in 2016. The report revealed that the none of the Veteran’s heart conditions qualify within the generally accepted medical definition of ischemic heart disease (IHD). The Veteran does not have a myocardial infarction (MI), congestive heart failure (CHF), cardiac arrhythmia, heart valve condition, and pericardial adhesions. He has not had infectious cardiac conditions, including active valvular infection (including rheumatic heart disease), endocarditis, and pericarditis or syphilitic heart disease. The examiner concluded that the Veteran does not have diagnosed or established atherosclerotic coronary artery disease and/or congestive heart failure. The August 2016 VA examiner opined that the Veteran’s heart condition is less likely as not (less than 50 percent probability) incurred in or caused by an in-service injury, event or illness. The examiner explained that the Veteran does not have an official and established diagnosis of congestive heart failure or coronary artery disease. The examiner stated that the Veteran had a diagnosis of longstanding essential hypertension, resulting in hypertensive heart disease but the Veteran was never evaluated, treated, or managed for hypertension or any other cardiovascular-related condition while on active duty. The Board has considered the Veteran’s lay assertions. Lay persons are competent to offer testimony regarding observable symptomatology. However, while lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the diagnosis of ischemic heart disease and whether it is related to service, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1376 (2007). Hence, the Veteran’s opinion that he has diagnosed ischemic heart disease that is related to service, is not competent evidence and is entitled to no probative weight. While the Board has considered the Veteran’s subjective complaints, it gives greater weight to the objective medical evidence and the opinion of the August 2016 VA examiner. Therefore, the preponderance of the evidence is against the claim for service connection for ischemic heart disease; thus, the benefit of the doubt rule does not apply. Accordingly, service connection for ischemic heart disease must be denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Entitlement to service connection for amyloidosis The Veteran filed a March 2015 claim for service connection for amyloidosis. See March 2015 VA Form 21-526EZ. The Veteran’s service treatment records do not support any treatment, diagnoses, or reports of amyloidosis. Further, an April 1971 report of medical examination at separation indicated the Veteran had normal lymphatics and normal endocrine system. Post-service treatment records are also negative for treatment, diagnoses, or reports of amyloidosis. Significantly, the Veteran was afforded an August 2016 VA hematologic and lymphatic conditions examination and the report indicated that the Veteran does not now have nor has he ever been diagnosed with a hematologic or lymphatic condition. The report revealed the Veteran has not completed any treatment and is not currently undergoing any treatment for any hematologic or lymphatic condition, including leukemia. He does not have anemia or thrombocytopenia, including that caused by treatment for a hematologic or lymphatic condition. The Veteran does not currently have any findings, signs and symptoms due to a hematologic or lymphatic disorder or to treatment for a hematologic or lymphatic disorder. He does not currently have recurring infections attributable to any conditions, complications or residuals of treatment for a hematologic or lymphatic disorder. The August 2016 VA examiner opined that the Veteran’s claimed amyloidosis is less likely as not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness. The examiner stated that the Veteran does not have an official and established diagnosis of amyloidosis. The examiner explained that he had two different negative abdominal fat pad biopsies, in 2016, for amyloidosis and no amyloid (protein) deposits were found. Although the Veteran believes that he has amyloidosis and that such is attributable to service, he is not competent to provide a diagnosis in this case or opine as to the etiology of the condition. These issues are medically complex, and require specialized medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence, which demonstrates that the Veteran does not have amyloidosis. Accordingly, service connection for amyloidosis must be denied. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Therefore, the Board finds that the preponderance of the evidence is against the claims for service connection for amyloidosis, and that the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. “Staged” ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). 6. Diabetes mellitus with erectile dysfunction and renal insufficiency Service connection for diabetes mellitus with erectile dysfunction and renal insufficiency associated with herbicide exposure was granted in an August 2010 rating decision and assigned a 20 percent evaluation, effective January 22, 2010. The Veteran filed a December 2014 claim for increased rating for diabetes. See December 2014 VA Form 21-526EZ. The Veteran’s diabetes mellitus is rated under the criteria of 38 C.F.R. § 4.120 (diseases of the endocrine system), DC 7913 (diabetes mellitus). The rating criteria in relevant part are as follows: A rating of 20 percent is assigned for diabetes mellitus requiring insulin and restricted diet; or, oral hypoglycemic and restricted diet. A rating of 40 percent is assigned for diabetes mellitus requiring insulin, restricted diet and regulation of activities (avoidance of strenuous occupational and recreational activities). A rating of 60 percent is assigned for diabetes mellitus requiring insulin, restricted diet and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice per month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A rating of 100 percent is assigned for diabetes mellitus requiring more than one daily injection of insulin, restricted diet and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100 percent rating. Noncompensable complications are deemed part of the diabetic process under Diagnostic Code 7913; 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1) (2017). The Veteran was afforded a March 2015 VA diabetes mellitus examination and the report indicated that the Veteran had diagnosed type II diabetes mellitus. The report revealed that the Veteran’s diabetes was controlled with diet. He did not require regulation of activities as part of medical management of his diabetes mellitus. The Veteran visits his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times per month. He has not had any episodes of ketoacidosis requiring hospitalization over the past 12 months and has not had any episodes of hypoglycemia requiring hospitalization over the past 12 months. He has not had progressive unintentional weight loss attributable to diabetes mellitus. The Veteran has had progressive loss of strength attributable to diabetes mellitus. He sees his primary care physician approximately once every three months for his diabetes and has not had any episodes of ketoacidosis or hypoglycemia. A July 2016 VA medication management note indicated that the Veteran took oral medication for his diabetes mellitus. See July 2016 VA treatment note. Review of the evidence above shows the Veteran’s diabetes mellitus is managed by oral medication and by restrictive diet; he has not required insulin or restriction of activities. Accordingly, higher compensation under DC 7913 is not warranted. In sum, the Veteran’s diabetes mellitus more closely approximates the criteria for the currently assigned 20 percent rating for the entire period on appeal. Accordingly, the claim must be denied. Turning to the Veteran’s diabetic complications, the Board finds that a separate compensable rating is not warranted for the Veteran’s erectile dysfunction associated with diabetes mellitus. In this regard, the Veteran was afforded a March 2015 VA erectile dysfunction examination. The report revealed that the Veteran has erectile dysfunction and is not able to achieve an erection sufficient for penetration and ejaculation (without medication). Physical examination revealed normal penis. In order to receive a compensable rating under Diagnostic Code 7522 there must not only be erectile dysfunction, but there must also be competent evidence of a penile deformity, which is not shown here. 38 C.F.R. § 4.115b, Diagnostic Code 7522. Therefore, a separate compensable rating for erectile dysfunction is not warranted. Further, the Board notes the Veteran is already in receipt of special monthly compensation (SMC) for loss of use of a creative organ, effective January 22, 2010. See August 2010 rating decision. However, the Board finds that a separate 40 percent rating is warranted for urinary frequency as a diabetic complication under 38 C.F.R. § 4.115a. The March 2015 VA erectile dysfunction report revealed that the Veteran has urinary frequency dysfunction. This dysfunction causes increased urinary frequency with daytime voiding interval of approximately one hour and nighttime awakening to void five or more times. The March 2015 VA diabetes mellitus examiner associated the need to urinate five times during the night and hourly during the daytime to the Veteran’s diabetes mellitus. Accordingly, a separate 40 percent rating under 38 C.F.R. § 4.115a for urinary frequency is warranted for the entire period on appeal. 7. Bilateral lower extremity peripheral neuropathy The Veteran filed a December 2014 claim for increased ratings for left leg and right leg neuropathy. See December 2014 VA Form 21-526EZ. The Veteran is currently assigned 20 percent ratings for his right and left lower extremity peripheral neuropathy under Diagnostic Code 8520. Diagnostic Code 8520 addresses disability ratings for the sciatic nerve. It provides a 10 percent rating for mild incomplete paralysis, a 20 percent rating for moderate, a 40 percent rating for moderately severe, and a 60 percent rating for severe incomplete paralysis with marked muscular atrophy. Complete paralysis is rated 80 percent disabling. The Board observes that the terms “mild,” “moderate,” and “severe” are not defined in the regulations and rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. Although the use of the terms “mild,” “moderate,” and “severe” by VA examiners and others is evidence to be considered by the Board, it is not dispositive of the issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The Board finds that the Veteran’s bilateral lower extremity peripheral neuropathy symptoms more closely approximate the criteria contemplated in the moderately severe rating, to warrant a 40 percent evaluation. Here, the Board acknowledges that the March 2015 VA examiner assessed the Veteran’s lower extremity peripheral neuropathy symptoms as ranging from moderate to severe. Significantly, the March 2015 VA diabetic peripheral neuropathy examination report indicated the symptoms attributable to his diabetic peripheral neuropathy included moderate intermitted bilateral lower extremity pain; moderate right lower extremity paresthesias and/or dysesthesias; and severe left lower extremity paresthesias and/or dysesthesias. The Veteran had trophic changes (characterized by loss of extremity hair, smooth, shiny skin, etc.) attributable to diabetic peripheral neuropathy, including bilateral lower extremity hair loss from his knees down. He had mild bilateral lower extremity, incomplete paralysis of the femoral nerve and bilateral lower extremity, incomplete edema. He did not have muscle atrophy. The Veteran had pain with standing. Moreover, treatment notes throughout the record indicate that the Veteran has reported loss of sensation, pain, increased sensitivity, dysesthesia, and gait abnormality. Therefore, taking into consideration the Veteran’s reported symptoms and objective findings of lower extremity pain, lower extremity paresthesias and/or dysesthesias, trophic changes, and edema, the Board finds that the Veteran has experienced moderately severe peripheral neuropathy of the left and right lower extremities to warrant 40 percent ratings. However, a 60 percent rating is not warranted because the Veteran does not have muscle atrophy of either the left or right lower extremity. See March 2015 VA examination report. Therefore, a 40 percent rating, but no higher, for the entire period on appeal, is assigned for left lower extremity peripheral neuropathy and right lower extremity peripheral neuropathy. REASONS FOR REMAND 1. Entitlement to service connection for peripheral vascular disease A September 2012 VA vascular surgery consult note indicated that the Veteran has diagnosed chronic deep venous thrombophlebitis. See September 2012 VA vascular consult note. As noted above, herbicide exposure has been conceded. See August 2010 rating decision and Form DD-214. To date, the Veteran has not been afforded a VA examination for his claimed peripheral vascular disease. Thus, remand for VA examination is warranted. 2. Entitlement to service connection for male breast cancer The Veteran has a diagnosis of infiltrating ductal carcinoma of the breast. See August 2014 VA examination report. The August 2016 VA examiner opined that the Veteran’s condition is less likely as not (less than 50 percent probability) caused by or a result of the Camp Lejeune Contaminated Water (CLCW). However, the examiner did not address whether the Veteran’s breast cancer condition could otherwise be related to service, to include herbicide exposure. As such, remand is warranted. 3. Entitlement to service connection for a neurological condition Related to his claim for service connection for a neurological condition, the Veteran was afforded an August 2016 VA Parkinson’s disease examination. The report indicated that the Veteran does not now have nor has he ever been diagnosed with Parkinson’s disease (Paralysis agitans). Further, the August 2016 VA examiner opined that Parkinson’s disease was less likely as not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness. However, the Board notes that clarification is needed to ascertain whether the Veteran has a neurological condition other than Parkinson’s disease or lower extremity peripheral neuropathy that is related to service. In this regard, the Board notes that the May 2010 VA diabetes mellitus examination report indicated the Veteran had upper extremity neuropathy symptoms related to carpal tunnel syndrome. On remand, the examiner should determine the etiology of any diagnosed neurological disorder other than Parkinson’s disease or peripheral neuropathy of the lower extremities. The matters are REMANDED for the following action: 1. Obtain outstanding relevant VA treatment records and associate them with the claims file. 2. Schedule the Veteran for VA examination(s) to determine the nature and etiology of his claimed neurological condition, peripheral vascular disease, and male breast cancer. The examiner(s) is requested to review the claims file, to include this remand. Following review of the claims file, the examiner(s) should provide an opinion on the following: Male breast cancer The examiner should indicate whether it is at least as likely as not (a probability of 50 percent or greater) that the Veteran’s diagnosed carcinoma of the breast disability is caused by or related to service, to include herbicide exposure in service. Peripheral vascular disease (a) The examiner should indicate whether the Veteran has a currently diagnosed peripheral vascular disease disability, to include chronic deep venous thrombophlebitis. See September 2012 VA vascular consult note. (b) For any diagnosed peripheral vascular disease disability, the examiner should indicate whether it is at least as likely as not (a probability of 50 percent or greater) that the disability is caused by or related to service, to include herbicide exposure in service. Neurological condition (a) The examiner should indicate whether the Veteran has a diagnosed neurological disability, to include consideration of the May 2010 VA examination report, noting upper extremity neuropathy symptoms related to carpal tunnel syndrome. (b) For any diagnosed neurological disability other than Parkinson’s disease or lower extremity peripheral neuropathy, the examiner should indicate whether it is at least as likely as not (a probability of 50 percent or greater) that the disability is caused by or related to service, to include herbicide exposure in service. (c) For any diagnosed neurological disability other than Parkinson’s disease or lower extremity peripheral neuropathy, the examiner should indicate whether it is at least as likely as not (a probability of 50 percent or greater) that the disability is caused or aggravated by the Veteran’s service connected type II diabetes. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. If the examiner is unable to offer any requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. Ensure completion of the foregoing and any other development deemed necessary, then readjudicate the Veteran’s claims. If any claim remains denied, the Veteran should be provided with a Supplemental Statement of the Case and an opportunity to respond. The case should then be returned to the Board for appropriate appellate consideration. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Schick, Associate Counsel