Citation Nr: 21013750 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 17-16 943A DATE: March 10, 2021 ORDER Entitlement to service connection for the aggravation of hypertension by diabetes mellitus is granted. Entitlement to service connection for cerebrovascular accident residuals, due to service-connected diabetes mellitus and hypertension, is granted. Entitlement to service connection for left lower extremity diabetic peripheral neuropathy is granted. Entitlement to a 100 percent schedular rating for PTSD is granted. REMANDED Entitlement to service connection for erectile dysfunction is remanded. Entitlement to service connection for onychomycosis is remanded. Entitlement to a rating in excess of 20 percent for diabetes mellitus is remanded. Entitlement to an initial compensable rating for chronic kidney disease is remanded. Entitlement to a total rating for compensation purposes based on individual unemployability due to service connected disabilities (TDIU) is remanded. Entitlement to special monthly compensation based on the need for regular aid and attendance or at the housebound rate is remanded. FINDINGS OF FACT 1. Service connection has been established for diabetes mellitus, right lower extremity diabetic peripheral neuropathy, chronic kidney disease, PTSD, and obstructive sleep apnea. 2. It is at least as likely as not that hypertension was aggravated by service-connected diabetes mellitus. 3. It is at least as likely as not that cerebrovascular accident residuals are related to service-connected diabetes mellitus and hypertension. 4. Left lower extremity diabetic peripheral neuropathy is related to the service-connected diabetes mellitus. 5. PTSD is shown to be productive of total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for the aggravation of hypertension by diabetes mellitus have been met. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.310(a). 2. The criteria for service connection for cerebrovascular accident residuals due to hypertension and diabetes mellitus have been met. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.310(a). 3. The criteria for service connection for left lower extremity diabetic peripheral neuropathy have been met. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.310(a). 4. The criteria for a 100 percent schedular rating for PTSD are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from July 1966 to May 1989. He served in the Republic of Vietnam. The Veteran is incompetent for Department of Veterans Affairs (VA) benefit purposes. The Appellant is the Veteran’s spouse who has been appointed as the custodian payee. Service Connection Service connection may be established for chronic disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Service connection may also be established for disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Service connection shall be established on a secondary basis under the provisions of 38 C.F.R. § 3.310(a) where it is demonstrated that a service-connected disability has aggravated a nonservice connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Service connection has established been for diabetes mellitus, right lower extremity diabetic peripheral neuropathy, chronic kidney disease, PTSD, and obstructive sleep apnea. Hypertension VA clinical documentation dated in July 2002 states that the Veteran was diagnosed with hypertension. A September 2020 evaluation from M. Blevins, M.D., notes that the Veteran’s claim file had been reviewed. The doctor diagnosed hypertension. The doctor concluded that the “service connected Type II diabetes mellitus has permanently aggravated his hypertension.” The doctor clarified that “the records show that [the Veteran] has had non compliance with therapy to his diabetes, which has resulted in elevated glucose levels over the years and the progression from essential hypertension to malignant hypertension, confirming permanent aggravation of his hypertension by his service connected diabetes mellitus.” The Veteran has been diagnosed with hypertension by both VA and private physicians. Dr. Blevins determined that the hypertension was aggravated by the service connected diabetes mellitus. The Board of Veterans’ Appeals (Board) finds that the evidence is in at least equipoise as to whether the diagnosed hypertension has been aggravated by service-connected diabetes mellitus. Resolving all reasonable doubt in the Veteran’s favor, the Board concludes that service connection for the aggravation of hypertension, due to diabetes mellitus, is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Cerebrovascular Accident Residuals VA clinical documentation dated in December 2013 indicates that the Veteran suffered a cerebrovascular accident in September 2013. The September 2020 evaluation from Dr. Blevins notes that the Veteran’s claim file had been reviewed. The Veteran was noted to have experienced cerebrovascular accidents (strokes) in 2013, 2014, and 2018. The doctor concluded that “it is my opinion that it is at least as likely as not that the Veteran’s service connected Type II diabetes mellitus, as well as his hypertension, have resulted in his stroke.” She clarified that “literature from the National Stroke Association shows that people who have diabetes are two to four times more likely to have a stroke than people who do not have diabetes” and “research shows that hypertension is a significant and independent risk factor for hemorrhagic stroke.” The Veteran has been reported to have experienced three cerebrovascular accidents by both VA and private physicians. Dr. Blevins indicated that the cerebrovascular accidents were caused by the service connected diabetes mellitus and hypertension. The evidence is in at least equipoise as to whether the diagnosed cerebrovascular accident residuals are related to the service connected diabetes mellitus and hypertension. Resolving all reasonable doubt in the Veteran’s favor, the Board concludes that service connection for cerebrovascular accident residuals, due to diabetes mellitus and hypertension, is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Left Lower Extremity Disability Service connection has been established for diabetes mellitus. The report of a January 2021 VA examination states that the Veteran was diagnosed with left lower extremity diabetic peripheral neuropathy, a disability clinically associated with diabetes mellitus. Therefore, service connection for left lower extremity peripheral neuropathy is warranted. Increased Rating for PTSD Disability ratings are determined by comparing the Veteran’s current symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. A 30 percent rating is warranted for PTSD which is productive of occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although the individual is generally functioning satisfactorily with routine behavior and normal self care and conversation) due to symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, and recent events). A 50 percent rating requires occupational and social impairment with reduced reliability and productivity due to symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks occurring more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material or forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating requires occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and an inability to establish and maintain effective relationships. A 100 percent rating requires total occupational and social impairment due to symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, a persistent danger of hurting herself or others, an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The report of a February 2021 psychiatric examination conducted for VA states that the Veteran was diagnosed with PTSD and no other psychiatric disability. The examiner indicated that the PTSD was productive of total occupational and social impairment due to symptoms including a flattened affect; a depressed mood; anxiety; panic attacks more than once a week; mild memory loss, such as forgetting names, directions or recent events; difficulty in understanding complex commands; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work like setting; inability to establish and maintain effective relationships; impaired impulse control, such as unprovoked irritability with periods of violence; grossly inappropriate behavior; and neglect of personal appearance and hygiene. The service connected PTSD has been found at the February 2021 VA psychiatric examination to be productive of total occupational and social impairment. The Board therefore concludes that a 100 percent schedular rating for PTSD is warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.130, Diagnostic Code 9411. REASONS FOR REMAND 1. Entitlement to service connection for erectile dysfunction and onychomycosis is remanded. VA’s duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121 (1991). When VA obtains an evaluation, the evaluation must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). \ The Veteran has not been provided a VA evaluation which addresses the relationship between claimed erectile dysfunction and service-connected hypertension and cerebrovascular accident residuals or a VA evaluation which addresses the relationship between the diagnosed onychomycosis and service-connected diabetes mellitus. 2. Entitlement to a rating in excess of 20 percent for diabetes mellitus and a compensable rating for chronic kidney disease is remanded. Additional relevant VA clinical documentation was incorporated into the record in September 2020. In December 2020, the Board informed the Veteran of the receipt of the records and asked if he wanted to waive the right to have the Agency of Original Jurisdiction initially review the documentation. He was notified that if he did not respond within 45 days of the date of the Board’s letter, the Board would assume that he wished that the appeal be remanded to the Agency of Original Jurisdiction for review of the additional documentation. The Veteran did not respond to the Board’s notice. Therefore, the issues of increased ratings for diabetes mellitus and chronic kidney disease will be remanded to the Agency of Original Jurisdiction. Further, the Board notes that clinical documentation dated after May 2020 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran’s claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). 3. Entitlement to both TDIU and special monthly compensation based on the need for regular aid and attendance or at the housebound rate is remanded. In light of the Board’s grant of service connection for hypertension, cerebrovascular accident residuals, and left lower extremity diabetic peripheral neuropathy and a 100 percent schedular rating for PTSD, the Agency of Original Jurisdiction should readjudicate the claims of entitlement to TDIU and special monthly compensation based on the need for regular aid and attendance or at the housebound rate. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated him for any erectile dysfunction and onychomycosis and the service connected diabetes mellitus and chronic kidney disease. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s VA clinical documentation not already of record, including treatment records dated after May 2020. 3. Schedule the Veteran for a VA examination to assist in determining the nature and etiology of the claimed erectile dysfunction. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all erectile dysfunction disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified erectile dysfunction disability had its onset during active service or is related to any incident of service. (c) Opine whether it is at least as likely as not (50 percent probability or greater) that any erectile dysfunction disability is due to or the result of diabetes mellitus, hypertension, cerebrovascular accident residuals, and the other service-connected disabilities. (d) Opine whether it at least as likely as not (50 percent probability or greater) that any erectile dysfunction disability has been aggravated (increased in severity beyond the natural progression of the disorder) by diabetes mellitus, hypertension, cerebrovascular accident residuals, and the other service-connected disabilities. 4. Schedule the Veteran for a VA examination to assist in determining the nature and etiology of diagnosed onychomycosis. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all toenail disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified toenail disability had its onset during active service or is related to any incident of service. (c) Opine whether it is at least as likely as not (50 percent probability or greater) that any toenail disability is due to or the result of diabetes mellitus and the other service-connected disabilities. (d) Opine whether it at least as likely as not (50 percent probability or greater) that any toenail disability has been aggravated (permanently increased in severity beyond the natural progression of the disorder) by diabetes mellitus and the other service-connected disabilities. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. T. Hutcheson, 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.