Citation Nr: 21014026 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 14-27 940 DATE: March 11, 2021 REMANDED Service connection for neuropathy of the right upper extremity is remanded. Service connection for neuropathy of the left upper extremity is remanded. Service connection for neuropathy of the right lower extremity is remanded. Service connection for neuropathy of the left lower extremity is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1965 to November 1968. The Veteran provided testimony at a November 2017 Board hearing before the undersigned Veterans Law Judge. A complete transcript is of record. This appeal was previously before the Board in October 2020. The Board remanded the Veteran’s service connection claims for diabetes mellitus, type II, erectile dysfunction (ED), bilateral neuropathy of the upper extremities, and bilateral neuropathy of the lower extremities for further development. Specifically, the Board sought a determination of whether the Veteran’s service aboard the USS Ranger placed him within the 12 nautical mile territorial sea of Vietnam. Procopio v. Wilkie, 913 F.3d 1371 (Fed. Cir. 2019). If the Veteran was found to have been within the 12 nautical mile territorial sea of Vietnam, VA examinations were to be ordered to address the etiology of his ED and upper and lower extremity neuropathy. The deck logs from the Veteran’s ship were identified and examined and a VA memo dated October 21, 2020 found that exposure to herbicides was conceded based on the Veteran’s nautical service in the offshore eligible waters as defined in the Blue Water Navy Vietnam Veterans Act of 2019, Public Law 116-23. As a result of the favorable finding, the Veteran was afforded VA examinations in November 2020 for his ED and bilateral upper and lower extremity neuropathy. The examiner provided the requested nexus opinions regarding both ED and neuropathy. As such, the Board finds that there has been substantial compliance with the October 2020 Board remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). A subsequent December 1, 2020 rating decision granted the Veteran service connection for diabetes mellitus, type II and for ED. That decision is considered a full grant of benefits sought on appeal, and the appeal concerning diabetes mellitus, type II and ED are no longer before the Board. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997). Service connection for bilateral upper and lower extremities is remanded. The Veteran was afforded a VA examination for his bilateral upper and lower extremity neuropathy in November 2020. After an in-person examination and a review of the Veteran’s claims file, the examiner provided a negative nexus opinion. The examiner explained that the Veteran’s post-service treatment records clearly document his neuropathy being related to a Vitamin B12 deficiency. The examiner also noted that the Veteran’s diabetes was well-controlled with only a single dose of metformin. Here, the October 2020 Board remand directives asked the examiner whether the Veteran was diagnosed with diabetic peripheral neuropathy of the upper and lower extremities. The examiner answered that question and also provided a nexus opinion. As such, the Board finds that there has been substantial compliance with the October 2020 Board remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). However, the Board nonetheless finds that a new VA examination should be afforded to the Veteran based on several factors. First, although the post-service records do show that his neuropathy has been attributed to a B12 deficiency; there is evidence that he indeed does have diabetic neuropathy. See Private Treatment Record dated March 11, 2011. Further, VA received correspondence from the Veteran’s representative stating that those with diabetes have an increased risk of B12 deficiency because it may be a side effect of metformin, a common treatment for diabetes mellitus, type II. See Third Party Correspondence received December 2, 2020. The correspondence also contained a link to an internet article about diabetes and B12 deficiency. See https://www.healthline.com/health/diabetes/b12-what-you-need-to-know#complications-of-b--12-deficiency. The Veteran’s representative also stated that the Veteran was not afforded an opinion on whether his B12 deficiency was caused by his diabetes, or diabetes medication. Here, the Board agrees with the Veteran’s representative and finds that another remand is necessary to afford the Veteran a VA examination that addresses this theory to entitlement to service connection. Accordingly, service connection for bilateral upper and lower extremity neuropathy is remanded. The matters are REMANDED for the following action: Schedule the Veteran for a VA examination to address the etiology of his bilateral upper and lower extremity neuropathy. The examiner is asked to address the following questions: a) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s bilateral upper and lower extremity neuropathy was caused by his service-connected diabetes, to include the use of metformin to treat the diabetes? Why or why not? In so doing, the examiner should also address the Veteran’s post-service records that indicated in March 2011 that he had a history of “diabetic neuropathy”. See Medical Treatment Record – Non-Government- Facility received March 20, 2013. The examiner should also address the internet article provided by the Veteran’s representative that suggests that metformin can lead to a Vitamin B12 deficiency. See Third Party Correspondence received December 2, 2020. (https://www.healthline.com/health/diabetes/b12-what-you-need-to-know#causes-of-b--12-deficiency). b) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s peripheral neuropathy of any of his 4 extremities was aggravated (made worse) by his diabetes mellitus? Why or why not? MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Fu, 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.