Citation Nr: 21003684 Decision Date: 01/22/21 Archive Date: 01/22/21 DOCKET NO. 15-06 149 DATE: January 22, 2021 REMAND Entitlement to service connection for peripheral neuropathy of the bilateral upper extremities, to include as due to exposure to herbicide agents is remanded. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities, to include as due to exposure to herbicide agents is remanded. REASONS FOR REMAND The Veteran had active military service from October 1965 to January 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In June 2018, the Veteran testified at a hearing. The transcript of the hearing is of record. By way of background, in October 2018 and July 2020, the Board remanded the issues on appeal for further evidentiary development. The Board finds that additional development is needed before the Veteran’s claim can be decided, as the Board finds that VA did not substantially comply with the July 2020 Board remand. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for peripheral neuropathy of the bilateral upper extremities, to include as due to exposure to herbicide agents is remanded. 2. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities, to include as due to exposure to herbicide agents is remanded. In July 2020, the Board remanded the issues on appeal as the prior October 2018 remand directives had the wrong standard when asking whether the Veteran’s peripheral neuropathy of the bilateral upper and lower extremities were caused or aggravated by his service-connected Type II diabetes mellitus. The Board incorrectly included the phrase “permanently aggravated,” when permanent aggravation is not required. See Ward v. Wilkie, 31 Vet. App. 233 (2019). Pursuant to the July 2020 Board remand order, an addendum opinion was obtained. In the August 2020 VA addendum opinion, the examiner opined that the Veteran’s peripheral neuropathy of the bilateral upper and lower extremities are less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the service treatment records do not mention nerve complaints or conditions. The post-service records show evaluation in 2007 for complaints of progressive numbness and pain more in the feet than in the hands. An August 2007 electromyography (EMG) showed moderate degree of sensory motor neuropathy of the lower extremity. In October 2008, the Veteran was diagnosed with peripheral neuropathy due to B12 deficiency with no diagnosis of diabetes mellitus as evidenced by normal blood glucose levels. The earliest evidence of impaired glucose tolerance was in November 2009 with glucose level of 105 and A1C level of 6.3. By October 2011, the Veteran’s A1C was mildly elevated at 6.7 and the Veteran was diagnosed with early diabetes. The examiner noted that the records show that in 2017 the Veteran was no longer receiving B12 supplements and his peripheral neuropathy was attributed instead to diabetes with no rationale. The Veteran’s neuropathy continued to worsen despite glucose and A1C level being in the normal range with minimal diabetic treatment. In January 2019, the Veteran was diagnosed with alcoholic cirrhosis. Peripheral neuropathy can be due to a variety of causes including alcohol and other drug toxicities, vitamin deficiencies, diabetes mellitus, and other conditions. The duration and severity of diabetes are a main risk factors for diabetic neuropathy, but diabetes that is very well controlled would not be expected to cause neuropathy. As such, the examiner opined that the Veteran’s peripheral neuropathy is considered less likely than not due to or significantly aggravated by his diabetes mellitus as the Veteran’s peripheral neuropathy began prior to development of diabetes; and his neuropathy progressed despite his diabetes markers being extremely well controlled and now normal. Instead, the examiner opined that the Veteran’s history of B12 deficiency and heavy alcohol use are stronger risk factors for neuropathy than well-controlled diabetes mellitus. The Board finds that the examiner applied the wrong standard for aggravation. Specifically, the examiner stated that the Veteran’s peripheral neuropathy is considered less likely than not due to or significantly aggravated by his diabetes condition. A finding of aggravation is worsening beyond normal progression. As it is unclear what constitutes as “significant” aggravation, the Board finds that a remand is warranted. The matters are REMANDED for the following action: Obtain an addendum opinion from the August 2020 examiner, or if unavailable from an appropriately qualified examiner, to determine the nature and etiology of the Veteran’s peripheral neuropathy of the bilateral upper and lower extremities. The claims file, including a copy of this remand, must be made available to be reviewed by the examiner. A record of the review of the claims file should be documented in the examination report. All indicated diagnostic tests should also be completed. The examiner must also determine if it is at least as likely as not (a fifty percent probability or greater) that the Veteran’s neuropathy of the bilateral upper and lower extremities were (a) caused by or (b) have been aggravated (worsened beyond the natural progress of the disorder) by the Veteran’s diabetes mellitus. The examiner should consider the August 2020 VA medical opinion that Veteran’s peripheral neuropathy is considered less likely than not due to or significantly aggravated by his diabetes mellitus. The examiner is reminded that a significant aggravation is not required. Aggravation is defined as worsening beyond the natural progress of this disorder. If aggravation is found, please identify to the extent possible the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to aggravation of the neuropathy of the bilateral upper or lower extremities by diabetes mellitus. A detailed rationale for the opinion must be provided. If the examiner is unable to offer the requested opinion, it is essential that he or she 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. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Noh, 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.