Citation Nr: 20048068 Decision Date: 07/17/20 Archive Date: 07/17/20 DOCKET NO. 14-24 223A DATE: July 17, 2020 REMANDED Entitlement to service connection for bilateral lower extremity peripheral neuropathy, to include as secondary to diabetes mellitus, is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from October 1966 to November 1968 with service in Vietnam from July 1967 to July 1968. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an August 2012 rating decision. In June 2018, a videoconference hearing was held before the undersigned; a transcript is in the record. In September 2018 the case was remanded for further development. [An April 2020 rating decision granted service connection for diabetes mellitus, type 2, at 20 percent, effective October 28, 2011; that issue is no longer before the Board.] On June 2019 VA diabetic peripheral neuropathy examination, diabetic peripheral neuropathy was not diagnosed. The Veteran reported that he received a diagnosis of neuropathy several years ago, that his symptoms began in association with back pain and have progressively worsened, and that he has not had an electromyograph (EMG) diagnostic study. He reported that he received epidural injections that did not provide relief and was scheduled for “extensive” lumbar surgery in July 2019. He reported pain and paresthesias in his bilateral lower extremities and pain in both buttocks that radiated down his thighs but did not extend past nor below his knees. He described the pain as a constant steady ache that felt like “electrical shocks” when he stood from a sitting to a standing position. He denied numbness or tingling in his lower extremities, and specifically denied numbness and tingling in his feet and ankles. He denied “stocking glove” distribution of symptomatology. The examiner noted that the Veteran had an MRI of his lumbar spine in August 2018 that showed extensive degenerative disc disease throughout the lumbar spine with severe high-grade canal stenosis. The examiner indicated that diabetes mellitus had been diagnosed and, on examination, moderate constant pain, intermittent pain, and paresthesias were noted in both lower extremities that were attributable to diabetic peripheral neuropathy. However, bilateral lower extremity diabetic peripheral neuropathy was not diagnosed. The examiner opined that although the Veteran endorsed symptoms that he attributed to peripheral neuropathy, his symptomology and physical examination were consistent with bilateral lower extremity radiculopathy associated with his lumbar spine degenerative disc disease [rather than diabetic neuropathy]. It was also noted that the Veteran was previously evaluated by neurosurgery as well as orthopedic surgery, and that his reported symptoms in those sessions were consistent with radiculopathy related to his degenerative spine condition. Further, a review of the medical record found no medical records that suggested that the Veteran had diabetic peripheral neuropathy. The examination is inadequate for rating purposes because it is somewhat internally inconsistent, and noncompliant with the September 2018 remand directives. The examiner attributed some of the Veteran’s symptoms to diabetic peripheral neuropathy (moderate constant pain, intermittent pain, and tingling in the lower extremities) but did not adequately distinguish those symptoms and the symptoms that are solely attributable to his low back disability. Also, the September 2018 remand directed that a neurological examination be conducted; however, although some elements of a neurologic examination were completed, the Veteran reported that he had not previously submitted to EMG testing, and no EMG or other similar nerve conduction testing was conducted on June 2019 examination. Another examination to obtain a fully adequate medical advisory opinion regarding the etiology of the Veteran’s claimed bilateral lower extremity peripheral neuropathy is necessary. A review of the record found that the last records of VA treatment associated with the claims file are from April 2020. As he receives ongoing VA treatment for leg pain, and records of such treatment may contain pertinent information, outstanding records of the treatment must be obtained and considered. The matter is REMANDED for the following: 1. Secure for the record any (and all) outstanding records of the Veteran’s VA evaluations and treatment for peripheral neuropathy/lower extremity pain. If such records are not available, explain for the record why that is so, and so advise the Veteran. 2. After the above development is completed, arrange for a neurological examination (to include diagnostic testing such as an EMG) of the Veteran to confirm the existence, and ascertain the likely etiology of any lower extremity peripheral neuropathy. The Veteran’s record must be reviewed by the examiner. Upon review of the record and interview and examination of the Veteran, the examiner should respond to the following: (a) Does the Veteran have peripheral neuropathy of either (or both) lower extremity(ies)? The examiner should, to the extent possible, differentiate symptoms (if any) that may be related to diabetic peripheral neuropathy from any that are attributable solely to a nonservice-connected disability (such as the Veteran’s low back disability). If neurological symptoms of the lower extremities found are determined to be attributable only to nonservice-connected radiculopathy from a service-connected low back disability and not also diabetic neuropathy, identify the clinical findings and medical principles that support the conclusion). (b) Identify the likely etiology for any peripheral neuropathy found. Specifically, is it at least as likely as not (a 50% or better probability) that it is etiologically related to his service (to include as due to exposure to Agent Orange/herbicide agents) or is a complication of/secondary to his service-connected diabetes mellitus? (c) If any peripheral neuropathy of the lower extremities is determined to not have been incurred in service or to be secondary to/a complication of diabetes, identify the etiology for the disability considered more likely. The examiner must include rationale with all opinions, with citation to supporting clinical data and medical principles (with citation to medical text or treatise, if possible). GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Bayles, 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.