Citation Nr: 20042040 Decision Date: 06/19/20 Archive Date: 06/19/20 DOCKET NO. 17-17 609 DATE: June 19, 2020 ORDER Entitlement to service connection for peripheral neuropathy of the right upper extremity is granted. Entitlement to service connection for peripheral neuropathy of the left upper extremity is granted. REMANDED Entitlement to a rating higher than 30 percent for ischemic heart disease is remanded. FINDINGS OF FACT 1. Peripheral neuropathy of the right upper extremity is as likely as not attributable to the service-connected diabetes mellitus type II. 2. Peripheral neuropathy of the left upper extremity is as likely as not attributable to the service-connected diabetes mellitus type II. CONCLUSIONS OF LAW 1. The criteria for service connection for peripheral neuropathy of the right upper extremity have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.310 (2019). 2. The criteria for service connection for peripheral neuropathy of the left upper extremity have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.310 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Navy from August 1964 to August 1968. Service connection may be established for disability resulting from personal injury sustained or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Secondary service connection may be established for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(b). See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Section 3.310 was amended effective October 10, 2006, this claim was filed after the amendment, and as such the current version of 38 C.F.R. § 3.310 is applicable to the claim on appeal. The Veteran appeals the denial of service connection for peripheral neuropathy of the left and right upper extremity. He argues that his disability is due to his service-connected diabetes mellitus type II. In the May 2015 VA examination, the Veteran was shown have diabetic peripheral neuropathy. The onset of the condition was deemed to be a complication of the Veteran’s diabetes in relation to the diabetes onset. In July 2015, however, another VA examiner found that the Veteran did not have and has never been diagnosed with diabetic peripheral neuropathy. The examiner noted that the Veteran has been seen for peripheral neuropathy complaints of pain and numbness in BUE/BLE in the hands/feet most likely due to Sjogren’s syndrome, with other less likely association with carpal tunnel syndrome and diabetes mellitus type 2. It was noted that the Veteran did have symptoms attributable to diabetic peripheral neuropathy. The examiner found that there was no pathology or diagnosis of any diabetic peripheral neuropathy of the bilateral upper or lower extremities. It was his medical opinion that the Veteran’s condition of no pathology or diagnosis of any diabetic peripheral neuropathy of the bilateral upper or lower extremities is less likely than not (less than 50 percent probability) proximately due to or the result of his diabetes mellitus type 2 since there was no condition found. The examiner further commented that the Veteran’s history, examination, and diagnostic studies are consistent with Sjogren's inflammatory arthritis and it is more likely than not that his sensorimotor peripheral neuropathy is secondary to Sjogren’s syndrome which is supported by the weight of the medical literature to have association with peripheral neuropathy. He further noted that the Veteran’s duration and severity of diabetes mellitus type 2 is not consistent with development of diabetic peripheral neuropathy. In January 2018, Dr. H expressed that he had been treating the Veteran for approximately 30 years. He stated that has “researched neuropathy in Up-To-Date and even pre-diabetes is associated with neuropathy.” According to Dr. H, diabetic neuropathy should be suspected in all patients with type 2 diabetes. He stated that enclosed was a list for the differential diagnosis of diabetic neuropathy and that Sjogren’s was not listed anywhere on the chart. He found that diabetes is a lot more common than Sjogren. Dr. H expressed that he has been in practice for 46 years and had seen two cases of Sjogren’s, and he felt that a diagnosis of Sjogren is certainly not on the top of the list to say that it is the cause of the Veteran’s neuropathy. He stated that diabetes would be much more likely a cause especially since the Veteran already has a 20 percent disability for diabetes. In sum, Dr. H stated that he would urge the VA to re-evaluate the Veteran’s case to include his neuropathy as caused by diabetes. In weighing the evidence of record, the Board finds in favor of the claim for service connection for peripheral neuropathy of the left and right upper extremity. In this regard, positive evidence has been submitted showing that the Veteran’s peripheral neuropathy of the left and right upper extremity is secondary to his service-connected diabetes mellitus type II. The Board finds that the opinions of the May 2015 VA examiner and Dr. H are persuasive and places the evidence at least in equipoise. Significantly, Dr. H has been treating the Veteran for approximately 30 years and he is a medical professional with the expertise to opine on the matter at issue in this case. He considered the Veteran’s peripheral neuropathy as it relates to his diabetes mellitus and his Sjogren’s syndrome, and based the opinion on a review of the medical literature, research and consideration of the Veteran’s medical history. Dr. H’s opinion is consistent with the opinion of the May 2015 VA examiner. The Board further notes that while the July 2015 VA examiner found that the Veteran did not have and has never been diagnosed with diabetic peripheral neuropathy, he nevertheless noted that the Veteran did have symptoms attributable to diabetic peripheral neuropathy. The Board finds that the latter findings are consistent with the opinions of the May 2015 VA examiner and Dr. H and further support the claims. As the Veteran’s peripheral neuropathy of the left and upper extremities have been positively linked to his service-connected diabetes mellitus type II, service connection on a secondary basis is warranted. Accordingly, the claims for service connection are granted. REASONS FOR REMAND The Veteran appeals the denial of a rating higher than 30 percent for his ischemic heart disease. The Veteran was last examined by VA in relation to this claim in May 2017. At that time, the Veteran was shown to have a METS level of greater than 5 but less than 7. The examiner noted that the Veteran’s METs level limitation was not due solely to the heart condition. He stated that the limitation in METs level was due to multiple medical conditions including the heart condition(s) and that it was not possible to accurately estimate the percent of METs limitation attributable to each medical condition. The examiner noted that the Veteran’s estimated METS level is confounded by his other comorbid medical conditions including right lumbar radiculopathy, osteoarthritis, rotator cuff syndrome, demyelinating peripheral polyneuropathy, inflammatory arthritis/Sjogren's syndrome, chronic pain syndrome, cervical spondylosis and mild obstructive lung defect, which combined lead to decreased exercise tolerance. In June 2017, the Veteran expressed disagreement with the examiners finding that the Veteran’s METS was cofounded by his other medical conditions. The Veteran disagreed with his shoulder issue and GERD being closely related to the heart. As there is some disagreement as the accuracy of the Veteran’s METs findings, the Board finds that another examination is warranted. On remand, another METS examination should be obtained to determine if the symptoms of the Veteran’s ischemic heart disease can be distinguished among his other medical conditions. If not, all limitations should be atttibutable to service-connected ischemic heart disease. See Mittlieder v. West, 11, Vet. App. 181 (1998). The matters are REMANDED for the following action: 1. Obtain and associate with the claims folder any outstanding VA and private outpatient treatment records. 2. Schedule the Veteran for a VA examination to address the current nature and severity of his ischemic heart disease. Access to electronic claims file must be made available to the examiner in conjunction with the examination. All clinical findings should be reported in detail. In accordance with the latest worksheets for rating ischemic heart disease, the examiner is to provide a detailed review of the Veteran’s pertinent medical history, current complaints and the nature and extent of his disability. The examiner must be sure to address the applicable rating criteria and address any functional impairment resulting from the disability. The examiner is requested to determine whether an exercise stress test is medically appropriate and, if not, provide an estimate of the Veteran’s workload capacity in terms of METS since December 2013. If the effects of non-service connected causes cannot be specifically delineated from the effects of service-connected ischemic heart disease, the examiner should attribute all workload capacity limitations to service-connected ischemic heart disease. A complete rationale for any opinion expressed must be provided. (continued on the next page) 3. Thereafter, consider all of the evidence of record and readjudicate the issue on appeal. If any benefit sought remains denied, issue a supplemental statement of the case to the Veteran and his representative. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T.S. Willie 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.