Citation Nr: 21074483 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 16-13 371 DATE: December 15, 2021 REMANDED Entitlement to service connection for peripheral neuropathy of the left upper extremity is remanded. Entitlement to service connection for peripheral neuropathy of the left lower extremity is remanded. Entitlement to service connection for diabetes mellitus is remanded. Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran had active-duty service from March 1968 to March 1970. He contends that he was exposed to herbicides during service in Korea along the Demilitarized Zone (DMZ). The Veteran testified before the undersigned Veterans Law Judge at a Board of Veterans' Appeals (Board) hearing at the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) in June 2019. This case was previously before the Board in September 2019, at which point the case was stayed pending the enactment of the Blue Water Navy Vietnam Veterans Act of 2019 (BWN Act), Pub. L. No. 116-23, 133 Stat. 966. After the BWN Act became effective January 1, 2020, the Board, in pertinent part, found that new and material evidence had been received to reopen the claims for service connection for peripheral neuropathy of the left upper and lower extremities, diabetes mellitus, ischemic heart disease, and hypertension, to include as secondary to ischemic heart disease. The Board then remanded the claims on the merits in January 2020. In April 2021, the Board granted service connection for ischemic heart disease based on presumed herbicide exposure and remanded the remaining claims. The case has been returned to the Board for appellate review. 1. Entitlement to service connection for peripheral neuropathy of the left upper extremity is remanded. 2. Entitlement to service connection for peripheral neuropathy of the left lower extremity is remanded. The Board cannot make a fully-informed decision on the issue of service connection for peripheral neuropathy of the left upper and lower extremities because no VA examiner has opined whether his diagnoses of record are related to his military service. The Board remanded the case so that a medical opinion could be provided as to whether the Veteran had early onset peripheral neuropathy that is presumptively related to his presumed herbicide exposure or if the Veteran's confirmed diagnoses of record were otherwise related to service. Private treatment records show the Veteran was diagnosed with bilateral median nerve disorder at the wrist as in carpal tunnel syndrome and sensorimotor polyneuropathy in July 2019. He also was diagnosed with predominant axonal greater than demyelinating type sensorimotor polyneuropathy of the lower extremities in July 2019. On remand, a September 2021 VA examiner found that the Veteran did not have a diagnosis of early onset peripheral neuropathy but did not address his confirmed diagnoses and whether these were related to his service. A supplemental opinion is warranted to address these outstanding questions. 3. Entitlement to service connection for diabetes mellitus is remanded. The Board cannot make an informed decision on the issue of service connection for diabetes mellitus as there is conflicting evidence of record as to whether the Veteran has a present diagnosis. The Veteran testified at the Board hearing that he was diagnosed with diabetes mellitus by Dr. Ongsiako in approximately 2003 and that he continues to receive treatment from Dr. Ongsiako every four to six months. On remand efforts were made to obtain all of the treatment records from Dr. Ongsiako. Treatment records as early as 2003 were not received, but none of the later records from Dr. Ongsiako indicate a diagnosis of diabetes. The records show that Dr. Ongsiako referred the Veteran for diagnostic testing done in December 2007, March 2011, July 2011, and November 2011, which shows elevated fasting glucose levels. The Veteran's urea nitrogen and BUN/ creatinine ratio was high in March 2011. Diagnostic tests conducted in January 2012 show fasting elevated readings for hemoglobin A1C, which notes that the Veteran was at an increased risk of diabetes. A September 2013 private treatment record from Dr. Ongsiako notes that the Veteran was pre-diabetic. A March 2016 private orthopedic treatment record notes in passing that the Veteran was not a diabetic. A June 2019 Quest diagnostics reading noted that the Veteran had a fasting glucose level of 128 mg/dL. The report noted that a glucose value higher than 125 mg/dL indicated that the patient might have a diagnosis of diabetes and that this should be confirmed with a follow-up test. A few years later, private eye examination records show a diagnosis of diabetes mellitus in December 2019 and July 2020 but there is no corresponding laboratory data to confirm the diagnosis. Also, a September 2021 VA examination report notes that the Veteran does not have diabetes. Specifically, the examiner noted that there would need to be two documented fasting glucose readings greater than 121 for a diabetes mellitus diagnosis and the Veteran only had one reading of 148 on examination in September 2021. The record shows, however, that the Veteran had previous elevated glucose readings that were higher than 121. See, e.g., Quest diagnostic records dated in December 2007 (128 mg/dL glucose), November 2011 (123 mg/dL fasting glucose), January 2013 (123 mg/dL glucose), September 2013 (130 mg/dL fasting glucose), and June 2019 (128 mg/dL fasting glucose). It is not clear if the September 2021 examiner meant that the two documented elevated fasting glucose readings needed to be on the same day or close together. On remand, it should be clarified based on the Veteran's medical history, and any further diagnostic testing, if indicated, whether the Veteran has a present diagnosis of diabetes. 4. Entitlement to service connection for hypertension is remanded. The Veteran contends that his hypertension is secondary to his ischemic heart disease. The Board remanded the case so that a VA examiner could determine whether the Veteran's hypertension is secondary to ischemic heart disease. A medical opinion was provided in September 2021 which addressed whether the Veteran's hypertension was incurred in service or caused or aggravated by the ischemic heart disease but did not address whether it was related to his presumed exposure to herbicides. A 2014 National Academy of Sciences Report (2014 NAS Update) that found "limited or suggestive evidence of association" between hypertension and herbicide agent exposure during service. This report should be considered in the supplemental opinion. See Garcia v. McDonough, No. 18-2245 (Memorandum Decision issued on August 17, 2021, the CAVC (Judge Falvey) setting aside and remanding the Board's denial of entitlement to service connection for hypertension finding that 2014 NAS Update was constructively before the Board). See also Euzebio v. McDonough, 989 F.3d 1305 (Fed. Cir. 2021). The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician whether the Veteran's diagnoses of a median nerve disorder at the left wrist as in carpal tunnel syndrome and sensorimotor polyneuropathy and predominant axonal greater than demyelinating type sensorimotor polyneuropathy of the left lower extremity (both diagnosed in July 2019) are at least as likely as not related to any event in service, including herbicide exposure; or otherwise (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. Also, if a diagnosis of diabetes mellitus is confirmed, please state whether his peripheral neuropathy of the left upper and left lower extremities is as likely as not proximately due to his diabetes mellitus; and/ or aggravated by the diabetes mellitus. The examiner is advised that a negative opinion cannot be based solely on the fact that the peripheral neuropathy (other than early-onset peripheral neuropathy) of the left upper and left lower extremity is not on the list of diseases that are presumptively associated with exposure to herbicide agents. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran presently has a diagnosis of diabetes mellitus. All necessary clinical testing should be completed. Also, the Veteran's complete medical history should be considered including the private eye examination records showing a diagnosis of diabetes mellitus in December 2019 and July 2020; and the elevated glucose readings higher than 121 documented since December 2007. See, e.g., Quest diagnostic records dated in December 2007 (128 mg/dL glucose), November 2011 (123 mg/dL fasting glucose), January 2013 (123 mg/dL glucose), September 2013 (130 mg/dL fasting glucose), June 2019 (128 mg/dL fasting glucose), and the September 2021 VA examination (148 mg/dL fasting glucose). 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's hypertension is at least as likely as not related to his presumed exposure to herbicides in service. In providing this opinion the clinician must consider a 2014 National Academy of Sciences Report (2014 NAS Update) that found "limited or suggestive evidence of association" between hypertension and herbicide agent exposure during service. S. L. Kennedy Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Sarah B. Richmond, 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.