Citation Nr: 21076445 Decision Date: 12/23/21 Archive Date: 12/23/21 DOCKET NO. 13-20 620 DATE: December 23, 2021 ORDER Service connection for left upper extremity peripheral neuropathy, to include as secondary to service-connected diabetes mellitus, is granted. FINDING OF FACT The evidence is at least in equipoise that the Veteran's left upper extremity peripheral neuropathy is etiologically related to his service-connected diabetes mellitus. CONCLUSION OF LAW The criteria for service connection for left upper extremity peripheral neuropathy as secondary to service-connected diabetes mellitus have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1967 to June 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a July 2014 Board hearing before the undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript is associated with the claims file. The Board remanded this matter most recently in April 2021 as inextricably intertwined with the Veteran's pending service connection claim for diabetes mellitus. Service connection for diabetes mellitus type II was granted by in July 2021 and the RO readjudicated the left upper extremity peripheral neuropathy thereafter. As such, the Board finds that the remand directives were substantially complied with, and further remand is unnecessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board notes that the record contains evidence not yet considered by the agency of original jurisdiction (AOJ); however, the claim of service connection for left upper extremity peripheral neuropathy may be granted on the current record. Therefore, the Board may proceed to the merits. 38 C.F.R. § 20.1305(c). The Veteran seeks service connection for left upper extremity peripheral neuropathy, which he contends is related to his now service-connected diabetes mellitus and/or his conceded herbicide agent exposure. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, service connection for a disability requires competent evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service; and (3) a causal relationship or nexus between the current disability and any injury or disease during service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may also be granted on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury, or for additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); 38 C.F.R. § 3.310. Veterans who served in the Republic of Vietnam during the period starting on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed to an herbicide agent, unless there is affirmative evidence of non-exposure. See 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307. The Veteran had qualifying service in the Republic of Vietnam during the applicable period; as such, herbicide agent exposure has been conceded. Service incurrence for certain diseases will be presumed on the basis of an association with certain herbicide agents (e.g., Agent Orange). See 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307 (a)(6), 3.309(e). Notably, the list includes "early onset peripheral neuropathy." Peripheral neuropathy is considered "early onset if abnormalities appear within 1 years after external exposure." Nat'l Acad. of Sci., Inst. of Med., Veterans & Agent Orange: Update 11 (2018) at 460. Here, the Veteran reported experiencing numbness in his arms early after his release from active duty but also testified that his left hand symptoms started a few years ago at the July 2014 Board hearing. See June 2014 Statement in Support of Claim; May 2016 Statement in Support of Claim; September 2014 Hearing Transcript. Per his VA treatment records, he was diagnosed with mild sensory peripheral neuropathy in July 2014 and reported onset of left hand symptoms three year prior. See July 2014 Neurology Consult. At an October 2015 VA examination, he reported that his left hand numbness began three years prior and the examiner determined that he did not have early onset peripheral neuropathy. As such, while the Board recognizes the Veteran's lay statements, the weight of the competent evidence indicates that he does not have early onset peripheral neuropathy of the left upper extremity, and presumptive service connection based on herbicide agent exposure is not warranted. 38 C.F.R. § 3.309 (e). The Board finds that a discussion of direct service connection is unnecessary, as service connection for left upper extremity peripheral neuropathy is warranted as secondary to the Veteran's service-connected diabetes mellitus. The Veteran was afforded VA examination assessing the nature and etiology of his left upper extremity peripheral neuropathy in October 2015, June 2021, and November 2021. At the October 2015 examination, the examiner indicated that the Veteran had mild idiopathic left upper extremity peripheral neuropathy and documented his neurologist's note that this condition may be associated with his metabolic syndrome and morbid obesity. The examiner ultimately determined, though, that he did not have early onset peripheral neuropathy, and it was less likely than not that his current neuropathy was associated with his conceded herbicide agent exposure. At the June 2021 examination, the examiner documented a 2011 diagnosis of idiopathic left upper extremity sensory neuropathy, the Veteran's prior treatment for metabolic syndrome, and the October 2019 diagnosis of diabetes mellitus. The examiner ultimately determined that the Veteran's left upper extremity sensory neuropathy was less likely than not proximately due to or caused by his diabetes mellitus, as its onset predated his diabetes mellitus diagnosis by eight years. The examiner separately determined that it was less likely than not that the Veteran suffered from diabetes mellitus in 2015 when he was being treated for metabolic syndrome, as his blood glucose levels did not meet the criteria for a diabetes mellitus diagnosis until October 2019. At the November 2021 examination, the examiner documented a 2010 diagnosis of bilateral upper and lower extremity peripheral neuropathy, the 2011 diagnosis of metabolic syndrome, and the 2019 diagnosis of diabetes mellitus. The examiner did not provide an opinion as to the Veteran's left upper extremity peripheral neuropathy, but as to his bilateral lower extremity peripheral neuropathy, opined that it is at least as likely as not due to and/or the result of his service-connected diabetes mellitus. The examiner quoted medical research as rationale, which specifically provided that, by far, the most common cause of neuropathy is diabetes, and "the prevalence of neuropathy in patients with diabetes is approximately 30%, and up to 50% will eventually develop neuropathy during the course of their disease." In mid-November 2021, the RO requested a clarification of the different diagnoses documented in the June 2021 and November 2021 examinations, which resulted in the November 2021 addendum opinion. The examiner opined that the Veteran's right lower extremity peripheral neuropathy was at least as likely as not related to service, as the Veteran's treatment records show that his peripheral neuropathy developed due to his underlying diabetes mellitus, and prior neurology notes show that he has metabolic syndrome and morbid obesity, which gave rise to diabetes mellitus, and he subsequently developed neuropathy from diabetes mellitus. The Board notes that the November 2021 initial and addendum opinions are not directed at the present claim, but rather the Veteran's now service-connected bilateral lower extremity peripheral neuropathy claims. The Board finds the November opinions probative of the present claim, though, as they together generally address the relationship between the Veteran's service-connected diabetes mellitus and overall neuropathy, as well as his metabolic syndrome and overall neuropathy, and provide rationale based in medical literature. The Board notes, however, that the November 2021 addendum examiner incorrectly indicated that the Veteran developed neuropathy subsequent to diabetes mellitus. As provided in the VA treatment records discussed below, the Veteran's overall neuropathy preceded his formal diagnosis of diabetes mellitus. Separately, the Board does not find the June 2021 opinion probative due its conclusory nature and the examiner's failure to consider the complete history of the Veteran's diabetes mellitus and neuropathy. The examiner did not provide a detailed rationale and did not reference any medical literature; instead, she merely relied on the time difference between the left upper extremity peripheral neuropathy diagnosis and the diabetes mellitus diagnosis without considering other factors such as the possible relationship of the Veteran's metabolic syndrome to both conditions. The Veteran's VA treatment records are associated with the claims file. In July 2014, although he had not yet been diagnosed with diabetes mellitus, his neurologist noted that diabetes mellitus could cause or contribute to his neuropathy after documenting his reported neuropathy symptoms of the bilateral upper and lower extremities. In October 2015, his physician, Dr. R.D., noted that he was "already manifesting diabetic type neuropathy from his years of metabolic syndrome." See October 2015 Primary Care Note. In January 2018, Dr. R.D. provisionally diagnosed him with "Type 2 Diabetes Mellitus with Diabetic Neuropathy, unspecified." See January 2018 Physical Medicine Rehab Consult. In August 2021, Dr. R.D. provided a statement as to the relationship between the Veteran's neuropathy and diabetes mellitus. Dr. R.D. indicated that she has treated the Veteran since 2015, at which time he was found to have metabolic syndrome, previously known as "pre-diabetes." She noted that metabolic syndrome has been "well-documented in it's [sic] ability to cause neuropathy and other end organ damage prior to the formal diagnosis of diabetes being made," and it "carries a high probability that a patient will develop diabetes with 5 years." She further noted that the Veteran "did in fact develop diabetes within 5 years of his diagnosis of metabolic syndrome" and "[a]t the time that he was diagnosed with diabetes type 2, he had already suffered the complications of glucose related neuropathy, as evidenced by his long-standing abnormal HgA1C levels." She concluded by stating that it is incorrect to assume that his neuropathy is not related to his hyperglycemia, now formally diagnosed as type II diabetes mellitus with neuropathy. The Board finds the statement from Dr. R.D. probative. Although Dr. R.D. did not explicitly opine that the Veteran's left upper extremity peripheral neuropathy is related to his service-connected diabetes mellitus, her statement details both the relationship between metabolic syndrome, diabetes mellitus, and neuropathy, and references medical literature in suggesting that the Veteran's neuropathy, generally, is due to his metabolic syndrome, which developed into diabetes mellitus. The Board notes that this statement, while not based on complete review of the claims file, reflects consideration of evidence and medical literature that the June 2021 opinion lacked. The Board has considered the Veteran's lay statements. Across several statements submitted by the Veteran, his wife, and his son, as well as his testimony at the July 2014 Board hearing, he was consistently reported as having left upper extremity numbness and tingling. After a review of the lay and medical evidence, the Board finds that service connection is warranted on a secondary basis for the Veteran's left upper extremity peripheral neuropathy. While the only opinion specifically addressing the etiology of the Veteran's left upper extremity peripheral neuropathy, the June 2021 opinion, does not support a finding of service connection, it is not probative due to its conclusory nature and lack of an adequate rationale. Because VA treatment records and the statement from Dr. R.D. suggest that this condition is related to his metabolic syndrome, which developed into diabetes mellitus, and the November 2021 opinions determined that his bilateral lower extremity peripheral neuropathy is related to his diabetes mellitus, the Board finds that the weight of the evidence indicates that this condition is also related to his service-connected diabetes mellitus. Other than the June 2021 opinion, which the Board affords no probative value, there is nothing in the record to suggest that the left upper extremity peripheral neuropathy may be due to any other cause. Accordingly, resolving reasonable doubt in favor of the Veteran, the Board finds that service connection is warranted as secondary to the service-connected diabetes mellitus, and the claim is granted. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Tierno 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.