Citation Nr: 21072784 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 14-15 759 DATE: December 6, 2021 REMANDED Entitlement to service connection for bilateral upper extremity peripheral neuropathy is remanded. Entitlement to service connection for bilateral lower extremity peripheral neuropathy is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1967 to December 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2011 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned at a hearing in January 2017. The Board remanded this matter in December 2017, June 2019, September 2020, and June 2021 for additional development. The matter is now returned to the Board for further appellate review. 1. Entitlement to service connection for bilateral upper extremity peripheral neuropathy is remanded. 2. Entitlement to service connection for bilateral lower extremity peripheral neuropathy is remanded. The Board remanded this matter in June 2021 to obtain medical opinions addressing the etiology of the Veteran's bilateral upper and lower peripheral neuropathy. Unfortunately, the medical opinions are inadequate to adjudicate the Veteran's claims. In the June 2021 remand, the Board requested the selected clinician clarify whether it is at least as likely as not that the Veteran's diagnosis of "prediabetes" or "impaired glucose tolerance" and/or his diagnosis of "pre-diabetic neuropathy" is related to his conceded exposure to herbicide agents in service. The June 2021 examiner provided a negative nexus opinion, in part, because the Veteran does not have diabetes, rather he has pre-diabetes, which "...is not tantamount to or the medical equivalent or legal equivalent of actually having diabetes." See June 2021 VA Examination. Further, the June 2021 examiner noted that although the Veteran's medical records indicate he has prediabetes and glucose intolerance, "...this is not a ratable disease or disability capable of service connection, and pre-diabetes is not one of the listed conditions subject to presumptive service connections." Id. In Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), the United States Court of Appeals for the Federal Circuit found that the term "disability" as used in 38 U.S.C. § 1110, "refers to the functional impairment of earning capacity, not the underlying cause of said disability." In this case, the June 2021 examiner did not address whether there is any functional impact related to the Veteran's pre-diabetes or impaired glucose tolerance and/or his diagnosis of pre-diabetic neuropathy. Further, prediabetes, impaired glucose tolerance, and pre-diabetic neuropathy are not a disorder which is listed under 38 C.F.R. § 3.309(e). As such, presumptive service connection is not available based on exposure to herbicide agents. Nonetheless, the fact that presumptive service connection is not available does not preclude the claim for service connection to be established on a direct basis. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The June 2021 examiner; however, did not opine whether the Veteran's prediabetes, impaired glucose tolerance, and pre-diabetic neuropathy are directly related to his conceded herbicide agent exposure as requested by the Board in the June 2021 remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). As the questions of functional impairment of earning capacity and entitlement to direct service connection were not addressed by the June 2021 VA examiner, that examination is inadequate. Remand is required to obtain an adequate medical opinion addressing whether any blood sugar regulation disorder, including "prediabetes," "impaired glucose tolerance," or "pre-diabetic neuropathy" was caused by exposure to herbicide agents during active-duty service. See El Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013) (holding that, when multiple theories of entitlement are at issue, the Board must ensure that the medical opinions of record directly address all theories reasonably raised by the record). The matters are REMANDED for the following action: 1. Obtain a medical opinion regarding the nature and etiology of the Veteran's diagnosis of "prediabetes," "impaired glucose tolerance" or "pre-diabetic neuropathy." The Veteran should only be scheduled for a new examination if deemed necessary by the selected examiner. The examiner must opine whether the Veteran's "prediabetes," "impaired glucose tolerance" and/or "pre-diabetic neuropathy" is at least as likely as not (50 percent or greater probability) related to an in-service injury, event, or disease, to include conceded exposure to herbicide agents. The selected clinician must address whether the Veteran's "prediabetes," "impaired glucose tolerance" and/or "pre-diabetic neuropathy" result in functional loss. If so, the examiner must opine whether the Veteran's "prediabetes," "impaired glucose tolerance" and/or "pre-diabetic neuropathy" functional loss is at least as likely as not related to his military service, to include conceded exposure to herbicide agents. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide a reason for doing so. The examiner's report must include a complete rationale for the opinion. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Zachery S.C. Luce, 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.