Citation Nr: 21003345 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 20-25 816 DATE: January 21, 2021 ORDER Entitlement to service connection for bilateral lower extremity diabetic peripheral neuropathy is granted. Entitlement to service connection for erectile dysfunction is granted. REMANDED Entitlement to service connection for any disorder to account for unexplained bleeding associated with exercise, to include rectal bleeding, to include as due to diabetes mellitus, and claimed as renal bleeding, is remanded. Entitlement to service connection for bilateral upper extremity peripheral neuropathy, to include as due to diabetes mellitus, is remanded. Entitlement to a compensable rating for bilateral hearing loss is remanded. FINDINGS OF FACT 1. The Veteran’s bilateral lower extremity peripheral neuropathy is proximately due to his service-connected diabetes mellitus type II. 2. The Veteran’s erectile dysfunction is caused by his prostate cancer. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral lower extremity diabetic peripheral neuropathy, as secondary to his diabetes mellitus type II, are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. 2. The criteria for entitlement to service connection for erectile dysfunction, as secondary to prostate cancer, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from April 1963 to April 1967. These matters come before the Board of Veterans’ Appeals (Board) on appeal from October 2013 (bilateral upper and lower extremity peripheral neuropathies) and December 2015 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). Regarding the October 2013 rating decision that denied service connection for bilateral upper and lower extremity peripheral neuropathy, the Veteran requested the RO reconsider these denials in a November 2013 VA Form 21-4138 asserting they were incorrect decisions. The Board liberally construes the November 2013 VA Form 21-4138 as a notice of disagreement (NOD) with the October 2013 rating decision, and that decision is therefore the one on appeal with respect to the Veteran’s bilateral upper and lower extremity peripheral neuropathy claims. 38 C.F.R. §§ 20.201 (2012), 20.302; Palmer v. Nicholson, 21 Vet. App. 434, 437 (2007) (VA has always been, and will continue to be, liberal in determining what constitutes a Notice of Disagreement) (quoting 57 Fed. Reg. 4088, 4093 (Feb. 3, 1992)). The Board has recharacterized the Veteran’s claim to ensure consideration of all diagnoses of record. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). These matters have been advanced on the docket pursuant to 38 C.F.R. § 20.902. Service Connection Generally, to establish service connection the evidence must show: (1) the existence of a present disability; (2) 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 in or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability proximately due to or aggravated by a service-connected disease or injury. See 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). To establish secondary service connection, a Veteran must show: (1) the existence of a present disability; (2) the existence of a service-connected disability; and (3) a causal relationship between the present disability and the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). 1. Entitlement to service connection for bilateral lower extremity diabetic peripheral neuropathy, is granted. The Veteran asserts that his bilateral lower extremity peripheral neuropathy is due to his service-connected diabetes mellitus type II. See November 2011, November 2013, and June 2015 VA Forms 21-4138. The Board agrees. Regarding element one of secondary service connection, a current disability, there is evidence both against and in favor of the claim. Against the claim is the October 2014 examiner’s opinion. At the October 2014 VA examination, the Veteran reported to the examiner that he was experiencing an intermittent burning sensation in his bilateral lower extremities. The October 2014 examiner noted an objective loss of strength in the Veteran’s lower extremities but concluded the Veteran did not have a current diagnosis of peripheral neuropathy of the lower extremities. In January 2015, the Veteran complained to a VA treatment provider that he was experiencing burning and tingling in his feet and in July 2015 during a podiatry visit, the Veteran was diagnosed with diabetic peripheral neuropathy via mon-filament testing. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Thus, the Board finds that element one of service connection is met. The Veteran is service-connected for diabetes mellitus type II and element two of secondary service connection is also met. Regarding the final element of secondary service connection, or nexus, the Board notes that VA podiatrists have associated the Veteran’s peripheral neuropathy with his diabetes by diagnosing “diabetic peripheral neuropathy.” See December 2018, March 2019 VA treatment records. Accordingly, element three of service connection is met and service connection for bilateral lower extremity diabetic peripheral neuropathy is warranted. 2. Entitlement to service connection for erectile dysfunction is granted. The Veteran asserts that his erectile dysfunction is proximately due to his service-connected disabilities. The Board agrees. The Veteran has a current diagnosis of erectile dysfunction and the November 2020 VA examiner opined that it was proximately due to the Veteran’s service-connected prostate cancer. Accordingly, all three elements of service connection are met and service connection for erectile dysfunction is granted. REASONS FOR REMAND 3. Entitlement to service connection for any disorder to account for unexplained bleeding associated with exercise, to include rectal bleeding, to include as due to diabetes mellitus, and claimed as renal bleeding, is remanded. The Veteran asserts that he is experiencing renal bleeding associated with exercise and attributes it to his exposure to herbicide agents in the Republic of Vietnam and his diabetes mellitus. See July 2015 VA Form 21-4138, November 2016 NOD. The Veteran also reported experiencing this condition since 1998. Id. On the same day the Veteran submitted his claim for “renal” bleeding, he reported to a VA treatment provider that he had been experiencing incontinence of bowel and bladder and bleeding associated with riding his bicycle. The examiner noted “rectal” bleeding. See July 2015 VA treatment records. In this regard, the Veteran was treated by a private examiner in December 2000 for rectal pain and bleeding. A VA treatment provider noted the Veteran was previously diagnosed with Giardia in August 2005. The Veteran, in 2005, was diagnosed with sigmoid polyps, left-sided diverticula, and internal hemorrhoids. See December 2005 private treatment records. In May 2009, the Veteran reported experiencing incontinence of bowel accompanied by blood. See May 2009 VA treatment records. In April 2010, the Veteran was treated by a VA treatment provider for leaking stool accompanied by blood. In January 2012, the Veteran reported to a VA treatment provider that he experienced unexplained rectal bleeding after a long walk. Alternatively, regarding a renal or kidney issue, the Board notes the Veteran’s blood urea nitrogen (BUN) and creatinine levels were normal in every available lab report in the medical evidence of record. See September 2004, April 2012 private treatment records; August 2006, February 2007, December 2007, March 2008, May 2009, April 2010, and October VA treatment records. The Veteran denied hematuria and/or dysuria throughout the appeal period. See June 2006, July 2018, November 2019, January 2020, July 2020, September 2020, and October 2020 VA treatment records. In October 2014, a VA examiner concluded the Veteran did not have any renal complications due to his diabetes mellitus. Based on the evidence of record, the Board finds it necessary to give the Veteran an opportunity to clarify the claim on appeal (rectal or renal bleeding) and afford him another opportunity to submit or identify outstanding relevant evidence. 38 C.F.R. § 3.155(d)(2) (VA will consider all lay and medical evidence of record in order to adjudicate entitlement to benefits). Additionally, all outstanding treatment records should be obtained and any necessary development, to include any examinations warranted by the submission of additional evidence, should be completed. 4. Entitlement to service connection for bilateral upper extremity peripheral neuropathy, to include as due to diabetes mellitus, is remanded. As noted above, the October 2013 rating decision is the one on appeal regarding the Veteran’s claim for bilateral upper and lower peripheral neuropathy. See November 2013 NOD. In October 2014, the Veteran submitted to the singular VA examination regarding this claim and reported that he was not experiencing any symptoms in his upper extremities, but that his lower extremities were symptomatic. Accordingly, the October 2014 VA examiner opined the Veteran had no current diagnosis of the upper extremities. On his May 2020 VA Form 9, the Veteran reported that he was experiencing stabbing pain, burning, and tingling in his upper extremities. The Veteran is service-connected for diabetes mellitus type II. Thus, the Board finds that an additional examination is warranted to determine the current nature and severity of the Veteran’s bilateral upper extremity disorder to account for his symptoms of stabbing pain, burning, and tingling. See Snuffer v. Gober, 10 Vet. App. 400 (1997). 5. Entitlement to a compensable rating for bilateral hearing loss is remanded. The Veteran asserts that he is entitled to a compensable rating for his service-connected bilateral hearing loss. See November 2016 NOD. In this regard, the Board notes the Veteran was last afforded a VA examination of his hearing loss in September 2015. Since that time, VA treatment providers have noted a worsening of the Veteran’s hearing loss, though no audiogram or Maryland CNC tests are available for review. See August 2016 VA treatment records. Accordingly, given the passage of over 5 years since the Veteran’s last audiological examination and medical evidence of a progression of the Veteran’s bilateral hearing loss, the Board finds an additional examination is necessary to determine the current severity of the Veteran’s audiological disability. See Snuffer, supra. All outstanding treatment records should also be obtained. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records, to include audiological testing results from August 8, 2016. 2. With any necessary assistance from the Veteran, obtain any outstanding relevant private treatment records. 3. Issue a VCAA letter addressing the Veteran’s claim of service connection for any disorder to account for unexplained bleeding associated with exercise, to include rectal bleeding, to include as due to diabetes mellitus, and claimed as renal bleeding. Request that the Veteran clarify whether he is claiming a disorder manifested by rectal bleeding or renal bleeding. 4. After completing the development indicated above, if warranted, schedule the Veteran for any necessary VA examinations and request nexus opinions regarding his claims for any identified unexplained bleeding disorders, to include as due to herbicide agents, to include as due to diabetes mellitus type II. 5. Then, schedule the Veteran for an examination to determine the nature and etiology of his claimed bilateral upper extremity disabilities, to include any diabetic peripheral neuropathy. The claims file should be made available to and should be reviewed by the examiner. The examiner should address the following: (a.) Please diagnose all current upper extremity disorders manifested by pain, numbness, tingling, and/or weakness, or any functional impairment of the upper extremities manifested by pain, numbness, tingling, and/or weakness even in the absence of a diagnosed disorder. (b.) For each disorder diagnosed or functional impairment identified in part (a), please opine as to whether it is at least as likely as not (50 percent or greater probability) that the disorder had its onset in or is otherwise etiologically related to the Veteran’s service, to include as a result of his presumed exposure to herbicide agents in Vietnam; (c.) For each disorder diagnosed or functional impairment identified in part (a), please opine as to whether it is at least as likely as not (50 percent or greater probability) that the disorder is proximately due to a service-connected disability, to include diabetes mellitus; (d.) For each disorder diagnosed or functional impairment identified in part (a), please opine as to whether it is at least as likely as not (50 percent or greater probability) that the disorder has been aggravated (worsened beyond natural progression) by a service-connected disability, to include diabetes mellitus. A complete rationale must be provided for all opinions expressed. If a requested opinion cannot be provided without resorting to speculation, the examiner should so state and explain why this is the case. 6. Then schedule the Veteran for a VA examination to determine the current nature and severity of his service-connected bilateral hearing loss. All findings should be reported in detail, including any functional effects associated with the Veteran’s bilateral hearing loss. S. BUSH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Rouse, 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.