Citation Nr: 21069152 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 20-16 304 DATE: November 17, 2021 REMANDED Entitlement to service connection for poor blood circulation of the bilateral lower extremities is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1964 to June 1991. This case comes before the Board of Veterans' Appeals (Board) on appeal from a December 2018 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that on his April 2020 VA Form 9 the Veteran initially requested a video conference hearing before a Veterans Law Judge. In October 2021, the Veteran submitted correspondence withdrawing his request for a hearing. The Board notes that this matter has been advanced on the docket pursuant to 38 C.F.R. § 20.900(c). Entitlement to service connection for poor blood circulation of the bilateral lower extremities is remanded. The Veteran claims that he has poor blood circulation in both legs due to exposure to Agent Orange in Vietnam or due to his service-connected diabetes mellitus or service-connected bilateral knee disabilities. See March 2015 letter, February 2018 VA Form 9, and December 2019 hearing transcript. At the outset, the Board notes that the Veteran has been awarded service connection for post-traumatic stress disorder, a right knee disability, a left knee disability, coronary artery disease, diabetes mellitus, bilateral tinnitus, bilateral lower extremity diabetic peripheral neuropathy (sciatica nerve) associated with diabetes mellitus, bilateral hearing loss, hypertension, and bilateral knee scars. Remand is required for a VA examination. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159 (2016). VA's duty to assist includes providing a medical examination when necessary to make a decision on a claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4). The RO did not provide the Veteran with an examination for his bilateral lower extremity disability claimed as poor blood circulation. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of a diagnosed disability or symptoms of disability, (2) establishes that the veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). Here, VA treatment records and private medical records provide evidence of a diagnosed disability or symptoms of a disability. Private treatment records regularly document a diagnosis of peripheral vascular disease with onset in May 2013. A June 2015 private opinion noted that the Veteran had a history of severe peripheral arterial disease with limiting claudication. July 2017 private hospitalization records note that the Veteran had both defined coronary and peripheral vascular insufficiency and was electively admitted for intervention regarding the right lower extremity and an angiography. August 2018, February 2019, and August 2019 VA treatment records note that the Veteran had peripheral vascular disease with 2 stents in this right lower extremity and 1 stent in his left lower extremity. The Veteran was afforded an in-person VA examination in April 2019 for a left knee disability. During the examination, the Veteran stated that he had arterial stents in his legs and suffered from claudication which limited his ambulation. An April 2019 private treatment record noted that the Veteran had occluded arteries in his legs. An August 2020 VA treatment record notes that in the last 6 months the Veteran had a "blood Coreg problem on his leg". Accordingly, the Board finds that the record contains evidence of a diagnosis or symptoms related to his claimed poor circulation in his legs to warrant a VA examination. Next, the Veteran has provided lay evidence in support of a nexus between his poor lower extremity blood circulation and his exposure to herbicides or, alternatively, his service-connected disabilities. The Board notes that a July 2020 VA memorandum conceded that the Veteran was exposed to herbicides. In addition, the Veteran testified in December 2019 that he experienced blood coagulation in his legs following right and left knee replacements and that he had stents placed in his legs due to his diabetes mellitus. With regard to a possible nexus, the Board notes that an August 2019 VA treatment treatment record noted that the Veteran was afforded a VA diabetic foot examination and was at moderate risk for diminished circulation as evidenced by absent or weakly palpable pulses. Accordingly, the Board finds that a VA examination is warranted to determine the etiology of any right or left leg diagnosis related to the Veteran's claimed poor blood circulation. The matters are REMANDED for the following action: 1. Schedule a VA examination to determine the nature and etiology of the Veteran's claimed bilateral lower extremity poor blood circulation. The Veteran's claims file, to include a copy of this remand, must be made available to the examiner in conjunction with the examination along with any other information the medical professional deems pertinent. A note that it was reviewed should be included in the opinion. The VA examiner is asked to identify all diagnosed right or left lower extremity disabilities. For each identified right or left lower extremity diagnosis opine as follows: a. Is it at least as likely as not (50 percent probability or more) that the Veteran's right or left lower extremity disability is causally or etiologically related to his military service, to include exposure to Agent Orange? b. Is it at least as likely as not (50 percent probability or more) that the Veteran's right or left lower extremity disability is caused by or etiologically related to any of his service-connected disabilities, to include his service-connected right knee disability, left knee disability, coronary artery disease, diabetes mellitus, bilateral lower extremity diabetic peripheral neuropathy, or hypertension? c. Is it at least as likely as not (50 percent probability or more) that the Veteran's right or left lower extremity disability was aggravated (any incremental increase in the right or left lower extremity disability beyond its normal progression) by his service-connected right knee disability, left knee disability, coronary artery disease, diabetes mellitus, bilateral lower extremity diabetic peripheral neuropathy, or hypertension, or any other service-connected disability? If it is determined that the right or left lower extremity disability is aggravated by a service-connected disability, to the extent possible, the examiner should indicate the approximate degree of disability or baseline before the onset of aggravation. 2. Then, readjudicate the claim. If the determination of the claim remains unfavorable to the Veteran, then issue a Supplemental Statement of the Case and afford him a reasonable period of time to respond before returning the case to the Board. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Palombi 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.