Citation Nr: 21068265 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 17-28 795A DATE: November 9, 2021 ISSUES Entitlement to service connection for peripheral vascular disease (PVD), left lower extremity as secondary to diabetes mellitus, type II with erectile dysfunction. Entitlement to service connection for peripheral vascular disease (PVD), right lower extremity as secondary to diabetes mellitus, type II with erectile dysfunction. REMANDED Entitlement to service connection for peripheral vascular disease (PVD), left lower extremity as secondary to diabetes mellitus, type II with erectile dysfunction is remanded. Entitlement to service connection for peripheral vascular disease (PVD), right lower extremity as secondary to diabetes mellitus, type II with erectile dysfunction is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 1967 to June 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). By way of background, the RO issued a January 2015 rating decision denying the Veteran's claims for service connection for left and right lower extremity peripheral vascular disease (PVD). Prior to the expiration of the appeal period, the Veteran submitted a private medical opinion in March 2015. Accordingly, the January 2015 rating decision did not become final because new and material evidence was received within one year of issuance of the rating decision. 38 C.F.R. § 3.156(b). In a March 2015 rating decision, the RO confirmed and continued the previous denial of the Veteran's service connection claims. The Veteran subsequently filed a timely appeal. In his June 2017 VA Form 9, the Veteran requested a live videoconference hearing at a local VA office. However, in March 2021 the Veteran submitted a statement indicating he wished to withdraw his hearing request. Accordingly, the Board finds that the hearing request is withdrawn. See 38 C.F.R. § 20.704 (d). For the reasons explained below, the Board finds that further evidentiary development is required before the claims on appeal can be adjudicated. 1. Entitlement to service connection for peripheral vascular disease (PVD), left lower extremity as secondary to diabetes mellitus, type II with erectile dysfunction is remanded. 2. Entitlement to service connection for peripheral vascular disease (PVD), right lower extremity as secondary to diabetes mellitus, type II with erectile dysfunction is remanded. The Veteran is claiming service connection for his left and right lower extremity PVD as secondary to his service-connected diabetes mellitus, type II with erectile dysfunction. The record contains an April 2014 arterial doppler of the bilateral lower extremities which reflected that at the time the Veteran's arterial brachial index (ABI) was 1.0. In consideration of the arterial doppler, Dr. R.W. explained that although the Veteran's ABIs were normal, the imaging indicated that the Veteran had triphasic wave forms in the right common femoral artery and superficial femoral artery which suggested that the Veteran had some PVD. Additionally, in April 2014 the Veteran's private physician Dr. B.T. completed a VA Artery and Vein Conditions Disability and Benefits Questionnaire (DBQ). The examiner noted that the Veteran had decreased circulation to both of his feet and diagnosed bilateral PVD. Dr. B.T., however, did not provide an opinion on the etiology of the disability at that time. The Board notes that Dr. B.T. subsequently provided opinions in May 2014 and January 2015 indicating that the Veteran had a diagnosis of bilateral PVD that was as least as likely as not related to his service-connected diabetes mellitus. In both opinions, though, Dr. B.T. failed to provide any rationale for his conclusions. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). As such, the Board finds that the May 2014 and February 2015 opinions of Dr. B.T. are insufficient for adjudication purposes. In January 2015 the Veteran was afforded a VA examination for his diabetes mellitus. The examiner indicated that she reviewed the claims file, including the April 2014 arterial doppler. In the "Remarks" section of that examination the examiner noted that the Veteran's 2014 ABI did not show that he had any PVD and therefore he did not have PVD which was attributable to type II diabetes. The examiner then went on to state that the Veteran's April 2014 ABI was normal in both legs and although it was noted that he may have some PVD due to non-compliant artery walls, there was nothing to suggest that finding was related to his diabetes. Instead, the examiner attributed the findings to aging. The Board however finds that the opinion of the January 2015 VA examiner is inadequate for adjudication purposes. The examiner's opinion is confusing as to whether the examiner has found that the Veteran has a diagnosis of PVD. The examiner has relied on the Veteran's April 2014 ABI to initially opine that the Veteran does not have any diagnosis of PVD. The examiner then went on to appear to acknowledge that the ABI did in fact show PVD, but the examiner determined that diagnosis could be due to the Veteran's aging, and was not related to his service-connected- diabetes mellitus. Unfortunately, as this opinion appears to contradict itself, the Board finds that there is insufficient competent medical evidence on file for the Board to make a decision on this claim. Once VA undertakes the effort to provide an examination when developing a claim, the exam must be an adequate one. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Accordingly, the Board finds a remand is necessary so that an adequate opinion can be obtained on the Veteran's claims for service connection for his left and right lower extremity PVD as secondary to his diabetes mellitus, type II with erectile dysfunction. Furthermore, additional and relevant evidence has been added to the claims file since the previous statement of the case (SOC) was issued in June 2016. This additional relevant evidence consists of a December 2020 VA Diabetes Mellitus DBQ. Given that this new evidence pertains to the claim and given that the Veteran has not waived consideration by the agency of original jurisdiction (AOJ), the RO must consider this evidence and reevaluate the claim. Accordingly, the Board finds that a remand is necessary for AOJ consideration of the additional evidence and the issuance of an supplemental statement of the case SSOC. The matters are REMANDED for the following action: 1. Make appropriate efforts to obtain and associate with the claims file any updated private or VA medical records identified and authorized for release by the Veteran. 2. Schedule the Veteran for a new VA examination (or telehealth interview(s), review(s) of the record, etc., if an in-person examination(s) is not feasible) by an appropriate clinician to determine the nature and etiology of the Veteran's claimed left and right lower extremity peripheral vascular disease. The claims folder and this remand must be made available to the examiner for review, and the examination report must reflect that such a review was undertaken. After performing any/all necessary testing, the examiner should provide responses to the following questions: (a) Identify the diagnosis of any right and/or left lower extremity artery or vein disease present since the Veteran filed his claim for service connection. The examiner should address and reconcile any current findings with any other previous diagnosis of an artery or vein disease(s) during the period on appeal. (b) Then, for any/all disabilities found during the appeal period: (1) Opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's claimed right and left lower extremity artery or vein disease is at least as likely as not related to an in-service injury, event, or disease. (2) Opine whether it is as likely as not (50 percent probability or greater) that the Veteran's claimed right and left lower extremity artery or vein disease was caused or aggravated by the Veteran's service-connected diabetes mellitus, type II with erectile dysfunction. With respect to the question of whether any aggravation was observed, the examiner is requested to address whether there has been any worsening, no matter how incremental, of the Veteran's claimed right and left lower extremity artery or vein disease. In providing the requested opinions, the examiner is to consider all lay statements of record carefully, VA treatment records, and private treatment records and evaluations. The examiner is asked to consider and discuss the April 2014 arterial doppler of the bilateral lower extremities. (3) If aggravation is found, the examiner should address the following medical issues to the extent possible: (1) the baseline manifestations of the Veteran's disabilities found prior to aggravation; and (2) the increased manifestations which, in the examiner's opinion, are proximately caused by the service-connected disability. The examiner must also remain mindful that a recent precedent case clarified that secondary service connection does not require "permanent" worsening of the condition being claimed by the service-connected disability and requires considering whether there has been any worsening, no matter how incremental, so even if not above and beyond the condition's natural progression. See Ward v. Wilkie, 31 Vet. App. 233 (2019). (Continued on next page.) 3. Then, after conducting any other development deemed necessary, readjudicate the Veteran's claim with consideration of the evidence added to the electronic record since the SOC in June 2016. If the benefit sought on appeal remains denied, provide the Veteran and his representative with a SSOC and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board. Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Nettey, 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.