Citation Nr: 21014508 Decision Date: 03/12/21 Archive Date: 03/12/21 DOCKET NO. 13-24 654 DATE: March 12, 2021 ORDER Entitlement to an initial rating in excess of 10 percent disabling, prior to March 26, 2019, for service-connected peripheral neuropathy of the right upper extremity and residual of cerebrovascular accident associated with diabetes mellitus, type II, is denied. Entitlement to an initial rating in excess of 10 percent disabling, prior to March 26, 2019, for service-connected peripheral neuropathy of the left upper extremity and residual of cerebrovascular accident associated with diabetes mellitus, type II, is denied. Entitlement to an initial rating in excess of 70 percent disabling, beginning March 26, 2019, for service-connected peripheral neuropathy of the right upper extremity and residual of cerebrovascular accident associated with diabetes mellitus, type II, is denied. Entitlement to an initial rating in excess of 60 percent disabling, beginning March 26, 2019, for service-connected peripheral neuropathy of the left upper extremity and residual of cerebrovascular accident associated with diabetes mellitus, type II, is denied. REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus, type II, is remanded. Entitlement to an initial rating in excess of 10 percent disabling for service-connected cerebrovascular accident is remanded. Entitlement to an initial rating in excess of 20 percent disabling for service-connected diabetes mellitus, type II, is remanded. Entitlement to special monthly compensation (SMC) beginning November 1, 2011, based on housebound status, is remanded. FINDINGS OF FACT 1. For the period prior to March 26, 2019, the Veteran’s peripheral neuropathy of the right upper extremity was characterized by mild paresthesias and/or dysesthesias and numbness; mild, moderate, severe incomplete paralysis and complete paralysis of all radicular groups were not shown. 2. For the period prior to March 26, 2019, the Veteran’s peripheral neuropathy of the left upper extremity was characterized by mild paresthesias and/or dysesthesias and numbness; mild, moderate, severe incomplete paralysis and complete paralysis of all radicular groups were not shown. 3. For the period beginning March 26, 2019, the Veteran’s peripheral neuropathy of the right upper extremity was characterized by severe incomplete paralysis of all radicular groups; complete paralysis was not shown. 4. For the period beginning March 26, 2019, the Veteran’s peripheral neuropathy of the left upper extremity was characterized by severe incomplete paralysis of all radicular groups; complete paralysis was not shown. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent disabling for peripheral neuropathy of the right upper extremity, prior to March 26, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.124a, Diagnostic Code 8513. 2. The criteria for an initial rating in excess of 10 percent disabling for peripheral neuropathy of the left upper extremity, prior to March 26, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.124a, Diagnostic Code 8513. 3. The criteria for an initial rating in excess of 70 percent disabling for peripheral neuropathy of the right upper extremity, beginning March 26, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.124a, Diagnostic Code 8513. 4. The criteria for an initial rating in excess of 60 percent disabling for peripheral neuropathy of the left upper extremity, beginning March 26, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.124a, Diagnostic Code 8513. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from July 1966 to October 1969. In April 2020, the Board remanded the claims for further development and adjudication. The Board finds that its prior directives were complied with regarding the issues decided herein. However, for the Veteran’s remaining claims, its prior directives were not substantially complied with and as will be discussed further an additional remand is necessary. A remand by the Board confers on the Veteran or other claimant, as a matter of law, the right to substantial, but not strict, compliance with the remand orders. See Stegall v. West, 11 Vet. App. 268 (1998). Increased Rating Claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). While the Veteran’s entire history is reviewed when making a disability determination, where service connection has already been established and an increase in the disability rating is at issue, it is a present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Court has held that, in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by the Veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, are expected in all instances. 38 C.F.R. § 4.21. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran’s service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. When 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). When there is an approximate balance of positive and negative evidence regarding the merits of an issue, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. If the preponderance of the evidence is against the claim, the claim is to be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Entitlement to initial ratings in excess of 10 percent disabling, prior to March 26, 2019, and in excess of 70 percent disabling thereafter, for service-connected peripheral neuropathy of the right upper extremity and residual of cerebrovascular accident associated with diabetes mellitus, type II, is denied; and entitlement to initial ratings in excess of 10 percent disabling, prior to March 26, 2019, and in excess of 60 percent disabling thereafter, for service-connected peripheral neuropathy of the left upper extremity and residual of cerebrovascular accident associated with diabetes mellitus, type II, is denied. The Veteran contends that his peripheral neuropathy of the bilateral upper extremities is worse than is reflected by his currently assigned ratings. As the Veteran’s appeal is of the initial ratings assigned, the entire appeal period is for consideration. The Veteran is right hand dominant; thus, it is considered his major extremity for rating purposes and the left upper extremity is considered the minor extremity. The Veteran’s peripheral neuropathy of the right upper extremity is rated as 10 percent disabling prior to March 26, 2019, and 70 percent disabling thereafter. The Veteran’s peripheral neuropathy of the left upper extremity is rated 10 percent disabling prior to March 26, 2019, and 60 percent disabling thereafter under Diagnostic Code 8513 of 38 C.F.R. § 4.124a. Diagnostic Code 8513 provides ratings for diseases of the peripheral nerves, paralysis of all radicular groups. For the major extremity, a 20 percent rating is afforded for mild, incomplete paralysis; a 40 percent rating for moderate, incomplete paralysis; a 70 percent rating for severe, incomplete paralysis; and a 90 percent rating for complete paralysis. For the minor extremity, a 20 percent rating is afforded for mild, incomplete paralysis; a 30 percent rating for moderate, incomplete paralysis; a 60 percent rating for severe, incomplete paralysis; and an 80 percent rating for complete paralysis. 38 C.F.R. § 4.124a, Diagnostic Code 8513. The term “incomplete paralysis,” with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. The ratings for the peripheral nerves are for unilateral involvement. Id. The words “slight,” “mild,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The Veteran’s post-service treatment records reflect his reports of bilateral hand tingling and numbness as well as weakness. Throughout the appeal, the Veteran has undergone many VA examinations. However, the ones pertinent to the Veteran’s claims for increased ratings for bilateral upper extremity peripheral neuropathy are those conducted in July 2012, March 2019 and November 2020. In July 2012 the Veteran underwent a VA Diabetic Sensory-Motor Peripheral Neuropathy examination with an accompanying disability benefits questionnaire (DBQ). The examiner noted that the Veteran was right hand dominant and that he suffered from diabetic peripheral neuropathy. The examiner noted that the Veteran experienced bilateral upper extremity mild paresthesias and/or dysesthesias and mild numbness. Strength testing revealed less than normal strength in right elbow flexion and extension, wrist flexion and extension, grip, and pinch, however left elbow and wrist flexion and extension were normal as were left grip and pinch. Deep tendon reflexes reflected decreased sensation, light touch/monofilament testing was decreased on the right side but normal on the left, position sense and vibration sensation was normal, cold sensation was decreased on the right but normal on the left. The examiner noted that the Veteran suffered muscle atrophy but no trophic changes. The examiner noted no paralysis of the radial, median, or ulnar nerves. In March 2019 the Veteran underwent a VA Peripheral Nerves Conditions examination with an accompanying DBQ. The examiner noted that the Veteran suffered from bilateral upper extremity peripheral neuropathy. The Veteran reported weakness in his hands as well as constant numbness and intermittent tingling. The Veteran also reported burning in his hands. The examiner noted that the Veteran is right hand dominant. The examiner also noted that the Veteran experienced moderate intermittent pain, paresthesias and/or dysesthesias, and numbness. Muscle strength testing was noted to be active movement against some resistance in left wrist flexion and extension and bilateral grip and pinch. However, bilateral elbow flexion and extension were normal as was right wrist flexion and extension. The examiner noted muscle atrophy and trophic changes. Reflex testing was hypoactive and sensory testing was decreased in the left inner/outer forearm and bilateral hand/fingers. The examiner noted bilateral severe incomplete paralysis of the median and ulnar nerves. In November 2020 the Veteran underwent a VA Peripheral Nerves Conditions examination with an accompanying DBQ. The examiner noted that the Veteran suffered from bilateral upper extremity peripheral neuropathy. The examiner noted moderate paresthesias and/or dysesthesias and numbness. Muscle strength testing was active movement against some resistance in right grip, but otherwise normal. The examiner noted no muscle atrophy or trophic changes. Reflex testing was normal, sensory testing was decreased bilaterally in the inner/outer forearm and hands and fingers. The examiner found that the radial, median, ulnar, musculocutaneous, circumflex, long thoracic, upper radicular group nerves were normal. The examiner noted that the middle radicular group experienced bilateral mild incomplete paralysis. The middle radicular group experienced bilateral moderate incomplete paralysis. The examiner noted that the Veteran’s peripheral nerve conditions impacted his ability to work in that they made it difficult for him to grip and grasp with his right hand which lead to issues completing administration and physical tasks at work. Throughout the appeal the Veteran submitted statements indicating his belief that his conditions are worse than is currently reflected. Period prior to March 26, 2019 Following a review of the relevant evidence of record, the Board concludes that for the period prior to March 26, 2019, initial ratings greater than 10 percent for both the right and left upper extremities peripheral neuropathy are not warranted. Prior to March 26, 2019, the most probative evidence pertinent to neuropathy in the upper extremities is the July 2012 VA examination as well as the post-service treatment records. Specifically, the Board notes that while the examiner reported the Veteran’s mild paresthesias and/or dysesthesias and numbness, he found no paralysis of the Veteran’s nerves. The Board finds that the evidence of record prior to March 26, 2019 demonstrates that the Veteran had, at most, mild paresthesias and numbness without any evidence of actual incomplete paralysis of all radicular groups in the right and left upper extremities. Specifically, his disabilities were manifested by no more than mild sensory and functional impairment, which does not more nearly approximate mild incomplete paralysis of all radicular groups. Consequently, peripheral neuropathy of the right and left upper extremities warrant no more than the currently assigned 10 percent disability ratings under Diagnostic Code 8513 prior to March 26, 2019. Period beginning March 26, 2019 Following a review of the relevant evidence of record, the Board concludes that for the period beginning March 26, 2019 initial disability ratings greater than 70 percent for right upper extremity peripheral neuropathy and 60 percent for left upper extremity peripheral neuropathy are not warranted. The evidence demonstrates findings of no more than severe incomplete paralysis of the right and left median and ulnar nerves. The March 2019 VA examiner noted severe incomplete paralysis with symptoms including moderate intermittent pain, paresthesias and/or dysesthesias and numbness, reduced muscle strength and some muscle atrophy and trophic changes. Based on this evidence, the record demonstrates that the Veteran had, at most, severe incomplete paralysis of all radicular groups of the right and left upper extremities. There is no evidence of complete paralysis. Consequently, peripheral neuropathy of the right upper extremity warrants no more than a70 percent rating and peripheral neuropathy of the left upper extremity warrants no more than a 60 percent rating on and after March 26, 2019 under Diagnostic Code 8513. The Board has considered all other potentially applicable Diagnostic Codes, but has found that no other Diagnostic Codes would result in more favorable findings. Therefore, the preponderance of the evidence shows that the Veteran is not entitled to ratings in excess of 10 percent disabling, for his bilateral upper extremity peripheral neuropathy prior to March 26, 2019, and in excess of 70 percent disabling for right upper extremity peripheral neuropathy and in excess of 60 percent disabling for left upper extremity peripheral neuropathy thereafter. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. Other Considerations The Board has considered whether further staged ratings under Hart, supra, are appropriate for the Veteran’s service-connected disabilities; however, the Board finds that his symptomatology has been stable for each disability throughout the appeal period. Therefore, assigning further staged ratings for such disabilities is not warranted. In assessing the severity of the disabilities under consideration, the Board has considered the Veteran’s assertions regarding his symptoms, which he is certainly competent to provide. See, e.g. Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the criteria needed to support higher ratings require medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134 (1994). As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any higher ratings pursuant to any applicable criteria at any point pertinent to this appeal. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However the preponderance of the evidence is against the claims, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. REASONS FOR REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claims so that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. In addition, as previously noted, where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall, 11 Vet. App. at 268. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus, type II, is remanded. The Veteran alleges that he suffers from hypertension, which was either caused by or aggravated by his service-connected diabetes mellitus, type II. The Board notes that VA’s duty to assist includes a duty to provide a medical examination or obtain a medical opinion where it is deemed necessary to make a decision on the claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4); Duenas v. Principi, 18 Vet. App. 512 (2004); Robinette v. Brown, 8 Vet. App. 69 (1995); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In addition, once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). For below noted reasons, the Board finds that, while the Veteran previously underwent VA examinations, an addendum opinion is needed for his claim for service connection for hypertension. In the Board’s April 2020 remand, the Board noted that the Veteran was afforded a VA examination in March 2019 to help determine the nature and etiology of his claimed hypertension. As part of the examiner’s rationale opining that the Veteran’s hypertension is not secondary to the service-connected diabetes mellitus, type II, the examiner stated that “secondary hypertension due to diabetes is almost always the result of end-organ involvement from diabetes (diabetic nephropathy).” The Board further noted that the Veteran’s medical records, to include the March 2019 VA examination, showed consistent diagnoses of diabetic nephropathy. Therefore, the Board determined that a clarification opinion was needed from the March 2019 examiner as to whether a negative etiology linking hypertension to the service-connected diabetes mellitus, type II was still appropriate and if so, to explain why this was so given the medical evidence demonstrating that the Veteran suffered from diabetic nephropathy. In December 2020, the Veteran underwent an additional VA Cardio Hypertension examination with an accompanying medical opinion. The examiner found that the Veteran’s condition was less likely than not proximately due to or the result of the Veteran’s service-connected condition as hypertension had its onset about the same time as his service-connected diabetes. In addition, the examiner noted that essential hypertension by definition had no clear identifiable cause. Furthermore he found no objective evidence of aggravation. However, the examiner failed to address the specific question posed by the Board or discuss the Veteran’s diagnosis of diabetic nephropathy. Therefore, an additional remand is necessary in order to comply with the Board’s prior request for clarification. See Stegall, 11 Vet. App. at 268. Entitlement to an initial rating in excess of 10 percent disabling for service-connected cerebrovascular accident is remanded. The Veteran contends that his service-connected cerebrovascular accident is worse than is reflected by his current rating. In the Board’s prior April 2020 remand, the Board noted that the Veteran’s VA medical records contained scanned records from University of Florida Health Shands Hospital from August 2 to 8, 2016. Furthermore, it was noted that he received treatment for his August 2016 stroke residuals at the VA medical center. However, the August 2016 stroke was not discussed in the Veteran’s March 2019 VA examination. Additionally, the medical evidence showed the Veteran suffered from slurred speech due to the August 2016 stroke. The Board found that an addendum medical opinion should be obtained to consider the symptoms as a result of the August 2016 stroke, and to provide an opinion as to whether the second stroke should also be considered to have been caused by the same cause for the first stroke, and in that sense, whether such was related to the first stroke. In November 2020 the Veteran underwent a VA Central Nervous System and Neuromuscular Diseases examination. While the examiner noted that the Veteran suffered strokes in both 2011 and 2016 and that they resulted in similar residuals, he did not address the specific questions posed by the Board. Specifically, the examiner failed to discuss whether the second stroke should be considered to have been caused by the same cause as that of the first stroke and whether the second stroke was related to the first. Therefore, an additional remand is necessary in order to comply with the Board’s prior request for clarification. See Stegall, 11 Vet. App. at 268. Entitlement to an initial rating in excess of 20 percent disabling for service-connected diabetes mellitus, type II, is remanded. The Veteran contends that his service-connected diabetes mellitus, type II is worse than is reflected by his current rating. Relevant to the Veteran’s claim for an increased rating for diabetes mellitus, type II, the Court has held that, where the record does not adequately reveal the current state of a claimant’s disability, fulfillment of the statutory duty to assist requires a contemporaneous medical examination, particularly if there is no additional medical evidence that adequately addresses the level of impairment of the disability since the last examination. Allday v. Brown, 7 Vet. App. 517, 526 (1995). The Board finds that the Veteran’s claim for an increased rating for his service-connected diabetes mellitus, type II, must be remanded in order to afford him a contemporaneous VA examination in order to assess the current nature and severity of his service-connected disability. In this regard, the record reflects that the Veteran was most recently afforded a VA Diabetes Mellitus examination in March 2019. Furthermore, due to the degenerative nature of the Veteran’s condition, in light of allegations of worsening symptoms, and the amount of time which has passed since the Veteran’s prior examination, the Board finds that a remand is required in order to afford the Veteran a contemporaneous VA examination so as to determine his current level of impairment with regard to his service-connected diabetes mellitus. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). Entitlement to SMC beginning November 1, 2011, based on housebound status, is remanded. The Veteran alleges that he is entitled to SMC based on housebound status as a result of his service-connected cerebrovascular accident. However regarding the Veteran’s claim for SMC, the Board finds it is inextricably intertwined with the claim for an increased rating for the Veteran’s service-connected cerebrovascular accident remanded herein. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Therefore, adjudication of the Veteran’s claim for SMC must wait for satisfactory development and adjudication of the remanded claim for an increased rating for service-connected cerebrovascular accident. Due to the amount of time which will pass on remand, updated treatment records should be obtained and associated with the record. The matters are REMANDED for the following action: 1. Obtain updated treatment records. 2. Obtain an addendum opinion from the March 2019 examiner or an appropriate clinician regarding whether the Veteran suffers from hypertension, as a result of his service-connected diabetes mellitus, type II. The examiner must opine whether the Veteran’s hypertension: a) At least as likely as not was (1) proximately due to service-connected diabetes mellitus, type II, AND/OR (2) was aggravated by service-connected diabetes mellitus, type II. In addition, the examiner is asked to discuss b) The Veteran’s diagnosed diabetic nephropathy and what impact if any such has on the examiner’s etiological opinion. The examiner must discuss the March 2019 VA examiner’s prior opinions in regards to diabetic nephropathy and what connection that implies between diabetes mellitus and hypertension. 3. The Veteran should be afforded a VA examination to determine the current nature and severity of his service-connected cerebrovascular accident. The claims file, to include a copy of this remand, must be made available and be reviewed by the examiner, and the examination report should note that review. Any indicated evaluations, studies, and tests should be conducted. In addition, the examiner is asked to discuss a) Whether the Veteran’s second stroke in 2016 should be considered to have been caused by the same cause as that of the first stroke in 2011? b) Whether the second stroke in 2016 was related to the first stroke in 2011? 4. The Veteran should be afforded a VA examination to determine the current nature and severity of his service-connected diabetes mellitus. The claims file, to include a copy of this remand, must be made available and be reviewed by the examiner, and the examination report should note that review. Any indicated evaluations, studies, and tests should be conducted. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Unger, 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.