Citation Nr: 20004481 Decision Date: 01/21/20 Archive Date: 01/21/20 DOCKET NO. 10-44 391A DATE: January 21, 2020 REMANDED Entitlement to service connection for right upper extremity peripheral neuropathy, to include as secondary to service-connected diabetes mellitus, type II, is remanded. Entitlement to service connection for left upper extremity peripheral neuropathy, to include as secondary to service-connected diabetes mellitus, type II, is remanded. Entitlement to service connection for right lower extremity peripheral neuropathy, to include as secondary to service-connected diabetes mellitus, type II, is remanded. Entitlement to service connection for left lower extremity peripheral neuropathy, to include as secondary to service-connected diabetes mellitus, type II, is remanded. REASONS FOR REMAND The Veteran served honorably on active duty with the United States Army from January 1968 to January 1970, to include service in the Republic of Vietnam. Regrettably, a remand is necessary in this case. The Regional Office (RO) promulgated a Statement of the Case (SOC) in September 2010. Since that date, and prior to the transfer of the case to the Board, additional VA and private medical treatment records have been added to the claims file. The Board acknowledges that the Veteran’s representative waived Agency of Original Jurisdiction (AOJ) review of this additional evidence in a June 2019 Informal Hearing Presentation. While the Veteran may waive AOJ review of additional evidence he submits himself, he may not waive AOJ review of evidence generated by VA prior to transfer of the case to the Board. In this case, as the VA treatment records were not submitted by the Veteran and were added to the claims file after the issuance of the SOC but prior to the transfer of the case to the Board, a remand is necessary for the issuance of a new Supplemental Statement of the Case (SSOC) that considers these additional records. 38 C.F.R. §§ 19.31, 19.37. Additionally, the Board finds that remand is warranted to afford the Veteran a VA examination in connection with his claims. The evidence shows the Veteran has been diagnosed with neuropathy, and VA treatment records suggest it may be related to his service-connected diabetes mellitus, type II. However, further information concerning the nature and etiology of the Veteran’s neuropathy is needed before the claims may be adjudicated, to include establishing which extremities are affected and to what extent. As the Veteran has not been afforded a VA examination in connection with his claims, one should be scheduled on remand. Accordingly, the matters are REMANDED for the following actions: 1. With any necessary assistance from the Veteran, obtain and associate with the claims file any outstanding VA and/or private medical treatment records. All efforts to obtain such records should be documented in the claims file. 2. Then, schedule the Veteran for a VA examination to determine the nature and etiology of his claimed peripheral neuropathy of the right and left upper extremities and right and left lower extremities. The examiner should complete an appropriate VA Disability Benefits Questionnaire (DBQ) that addresses the Veteran’s particular disability and severity of symptoms. The claims file must be made available to the examiner, who must review all pertinent records, including the Veteran’s service treatment records, post-service medical records, and lay statements. For any diagnosed peripheral neuropathy, the examiner must provide an opinion in response to the following questions: (a.) Is it at least as likely as not (a 50 percent or greater probability) that the disorder manifested during active duty service, or is otherwise related to active duty service, to include presumed exposure to herbicides therein? (b.) Is it at least as likely as not (a 50 percent or greater probability) that the disorder was caused or aggravated by the Veteran’s service-connected diabetes mellitus type II? Causation and aggravation are independent concepts and should have separate findings and rationales. See Atencio v. O’Rourke, 30 Vet. App. 74 (2018). As such, the VA examiner must provide separate findings and rationales relating to causation and aggravation. In all conclusions, the examiner must identify and explain the medical basis or bases, with identification of the evidence of record. If the examiner cannot offer an opinion without resorting to mere speculation, the examiner should explain why this is the case and identify any additional evidence that may allow for a more definitive opinion. 3. Then, readjudicate the claims on appeal. If the benefits sought remain denied, issue a supplemental statement of the case to the Veteran and his representative and return the case to the Board. L. CHU Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. T. Raftery, Associate 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.