Citation Nr: 21021606 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 14-41 639 DATE: April 13, 2021 ORDER Service connection for bilateral upper extremity neuropathy, as due to service-connected diabetes mellitus, is denied. A disability rating in excess of 30 percent for atherosclerotic heart disease with congestive heart failure, prior to January 5, 2017, is denied. A disability rating in excess of 20 percent for diabetes mellitus is denied. Special monthly compensation benefits based on the need for the regular aid and attendance of another person is granted. REMANDED Entitlement to service connection for bilateral lower extremity neuropathy, as due to service-connected diabetes mellitus, is remanded. FINDINGS OF FACT 1. The Veteran did not have a clinically diagnosed bilateral upper extremity peripheral neuropathy disability when he filed his claim or any time during the pendency of the claim. 2. Prior to January 5, 2017 the Veteran’s atherosclerotic heart disease with congestive heart failure was not manifested by more than one episode of acute congestive heart failure in the past year, or workload of greater than 3 METs, but not greater than 5 METs, which results in dyspnea, fatigue, angina, dizziness or syncope, or; left ventricular dysfunction with an ejection fraction (LVEF) of 30 percent to 50 percent. 3. Throughout the appeal, the Veteran’s diabetes mellitus was treated with at least one insulin injection per day and a prescribed oral hypoglycemic agent, without required regulation of activities as a part of his medical management. 4. The Veteran’s service-connected disabilities rendered him in need of regular aid and attendance of another person. CONCLUSIONS OF LAW 1. The criteria for service connection for a bilateral peripheral neuropathy disability have not been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. 2. The criteria for a rating in excess of 30 percent for atherosclerotic heart disease with congestive heart failure have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.104, Diagnostic Code 7005. 3. The criteria for a rating in excess of 20 percent for diabetes mellitus are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.119, Diagnostic Code 7913. 4. The criteria for special monthly compensation based on the regular aid and attendance of another person have been met. 38 U.S.C. § 1114 (l); 38 C.F.R. §§ 3.102, 3.350, 3.352(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from October 1965 to November 1967. He died in April 2017. The appellant is his widow, who has been properly substituted in this appeal. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued in September 2013 by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The appellant testified at a hearing before the undersigned Veterans Law Judge in February 2021. A transcript of that hearing has been associated with the record. During the appeal period, in a July 2019 rating decision, the Veteran’s disability rating for atherosclerotic heart disease with congestive heart failure was increased to 100 percent, effective January 5, 2017. As this represents the highest schedular evaluation possible for this disability as of this date, the appeal for the period after January 5, 2017 is no longer before the Board. However, to the extent that the highest possible evaluation was not assigned for the period prior to January 5, 2017, the claim for this period remains within the Board’s jurisdiction. See AB v. Brown, 6 Vet. App. 35 (1993). Finally, as indicated on the title page of this decision and as discussed below, the issue of entitlement to special monthly compensation based on aid and attendance has been raised by the record and is part and parcel of the claims for increased ratings decided herein. Akles v. Derwinski, 1 Vet. App. 118 (1991) (noting that the issue of entitlement to SMC is part and parcel of a claim for increased compensation and does not require submission of a separate claim). Service Connection The appellant is seeking entitlement to service connection for a bilateral upper extremity peripheral neuropathy disability for substitution purposes. She contends that the Veteran had a bilateral upper extremity peripheral neuropathy disability that was caused by his service-connected type II diabetes mellitus. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. at 448 (1995). The Board notes that the Veteran, in filing this claim, and the appellant, in pursuing it, have alleged only that the Veteran developed a bilateral upper extremity peripheral neuropathy disability on a secondary basis, as due to his service-connected diabetes mellitus. There is no evidence of record to indicate that the Veteran had a neuropathy disability that was directly due to his military service. Thus, the Board will only review this claim in the context of a secondary basis. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (Fed. Cir. 2009) (“Where a fully developed record is presented to the Board with no evidentiary support for a particular theory of recovery, there is no reason for the Board to address or consider such a theory”). However, in reviewing the evidence of record, the Board finds that the Veteran did not have a diagnosed bilateral upper extremity peripheral neuropathy disability at the time of his death, or at any time during the pendency of the appeal. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran’s post-service VA and private medical records do not show any diagnoses or treatment regarding the claimed bilateral upper extremity peripheral neuropathy disability. Importantly, a VA examination report from February 2013 shows that after examining the Veteran, an examiner found that he did not meet the criteria for bilateral upper extremity peripheral neuropathy. At that time, the Veteran specifically denied experiencing any neuropathic symptoms, such as tingling, in his hands. Thus, the Board finds that service connection is not warranted for bilateral upper extremity peripheral neuropathy. While the Veteran may have believed, and the appellant now asserts, that the Veteran had a bilateral upper extremity peripheral neuropathy disability, neither are not competent to provide such a diagnosis. Diagnosing a neurological disability requires specialized medical education and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The evidence of record does not show that the Veteran had, or appellant has, the requisite medical expertise to make such a diagnosis. Consequently, the Board gives more probative weight to the competent medical evidence of record, which shows no finding of bilateral upper extremity peripheral neuropathy. A necessary element for establishing entitlement to service connection is the existence of a current disability, as it is the cornerstone of a claim for VA disability compensation. Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997). In the absence of proof of a present disability there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Thus, the Board finds that the preponderance of the evidence is against the claim and entitlement to service connection for bilateral upper extremity peripheral neuropathy is not warranted. 38 U.S.C. § 5107 (b) (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The claim is denied. Increased Ratings Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. A veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). While the Veteran’s entire history is reviewed when assigning a disability rating, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, in evaluating a claim for a higher initial rating or increased rating, staged rating is appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). Heart disease, prior to January 5, 2017 The Veteran’s service-connected atherosclerotic heart disease with congestive heart failure (hereinafter, “heart disease”) has been rated under 38 C.F.R. § 4.104, Diagnostic Code 7005. Diagnostic Code 7005 provides for a 30 percent rating is assigned when a workload of greater than 5 metabolic equivalents (METs) but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or, with evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is assigned with more than one episode of acute congestive heart failure in the past year; when workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or for left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is assigned for chronic congestive heart failure; or when workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or for left ventricular dysfunction with an ejection fraction of less than 30 percent. One MET is defined as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). The Veteran underwent VA heart examinations in February 2013 and January 2017. In February 2013, the examiner noted that the Veteran did not have congestive heart failure. The Veteran’s METs were estimated to be between 5 and 7, and the Veteran reported experiencing angina. Diagnostic testing showed no evidence of cardiac hypertrophy or dilatation. The examiner determined that LVEF testing was not necessary at that time. By the time of the January 2017 VA examination, the Veteran was experiencing congestive heart failure that was chronic, and had cardiac hypertrophy and cardiac dilatation, as shown by testing. However, there had been no episodes of chronic congestive heart failure in the year prior to the examination. By this point, the Veteran’s METs were found to be between 1 and 3, and he experienced dyspnea and fatigue. Based on these findings, the Veteran’s disability rating for heart disease was increased to 100 percent, under Diagnostic Code 7005. A review of VA treatment records for the period prior to January 5, 2107 shows no incidents of either acute or chronic congestive heart failure or left ventricular dysfunction with an ejection fraction of 30 or higher. Based on the medical evidence of record, the Board finds that a rating higher than 30 percent is not warranted prior to January 5, 2017. The medical evidence of record does not show that a 60 percent rating is warranted, as medical evidence does not show that the Veteran experienced an episode of acute congestive heart failure, a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent, prior to January 5, 2017. In evaluating this claim, the Board has considered both the Veteran and appellant’s assertions regarding his symptoms, which they are certainly competent to provide. See Layno v. Brown, 6 Vet. App. 465, 470 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the criteria needed to support a higher rating for heart disease require medical findings, produced by specialized testing, that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134 (1994). Thus, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support a higher rating prior to January 5, 2017. Thus, the preponderance of the evidence is against a disability rating in excess of 30 percent for coronary artery disease. As the preponderance of the evidence is against the claim for a higher rating, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102; Gilbert, supra. The claim is denied. Diabetes Mellitus The Veteran’s service-connected diabetes mellitus has been assigned a 20 percent rating under Diagnostic Code 7913. Under that diagnostic code, a 20 percent rating is warranted for diabetes mellitus requiring insulin and restricted diet, or oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately rated. A maximum, 100 percent rating is warranted for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength, or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119, Diagnostic Code 7913. Within the criteria for a 100 percent rating, “regulation of activities” is defined as “avoidance of strenuous occupational and recreational activities.” This definition also applies to the “regulation of activities” criterion for a 40 percent rating under Diagnostic Code 7913. See Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). Moreover, medical evidence is required to support this criterion for a 40 percent rating. Id. at 364. The rating of diabetes mellitus under Diagnostic Code 7913 includes successive rating criteria, whereby “the evaluation of each higher disability rating included the criteria of each lower disability rating, such that if a component was not met at any one level, the Veteran could only be rated at the level that did not require the missing component.” See Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009); see also Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive ‘and’ in a statutory provision means that all of the conditions listed in the provision must be met). Note (1) to Diagnostic Code 7913 provides that compensable complications of diabetes are to be rated separately unless they are part of the criteria used to support a 100 percent rating (under Diagnostic Code 7913). Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1). Turning to the evidence of record, VA treatment notes throughout the appeal period consistently show that the Veteran treated his diabetes mellitus with medication and insulin injections. In February 2013, the Veteran underwent a VA diabetes mellitus examination. At that time, he was treating the condition with an oral hypoglycemic agent and insulin injections. The Veteran did not required regulation of activities as part of medical management of diabetes mellitus. He did not visit his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions, nor had he been hospitalized in the prior year for such. The only noted complications at that time was erectile dysfunction. The remaining record shows that insulin and oral medication remained the Veteran’s method of treating the condition. The Board notes that on at least one occasion in 2013, the condition was considered to be poorly controlled. However, by July 2016, the Veteran continued to take medication and inject insulin daily. He was advised to adhere to a diet of reduced carbohydrate and sugar intake. At no point during the appeal period do the records show that the Veteran was ever counseled by a health care provider to avoid strenuous occupational and recreational activities in order to control his condition. The appellant testified in February 2021 that, over the last few years of his life, the Veteran’s condition worsened to the point that he was no longer able to walk and was wheelchair bound. She testified that the Veteran became insulin dependent in 2015 and by the time of his death, his activities were restricted. Considering the above-cited evidence in light of the applicable rating criteria and rating considerations, the Board finds that a rating greater than 20 percent for the Veteran’s diabetes mellitus is not warranted. Specifically, while the evidence shows that the Veteran’s diabetes mellitus treatment consistently included at least one insulin injection per day and a prescribed oral hypoglycemic agent, the competent medical evidence of record shows that the Veteran was not required to regulate his activities due to his diabetes mellitus. As noted, Diagnostic Code 7913 defines regulation of activities as the avoidance of strenuous occupational and recreational activities, with medical evidence to support such avoidance. Here, there is no indication that the Veteran was ever told by a treating physician or any medical personnel that he needed to avoid strenuous activities to manage his disability. The Board acknowledges the appellant’s February 2021 testimony that the Veteran’s activities were restricted by his diabetes mellitus and that, by the end of his life, he was wheelchair bound. However, the rating criteria for a rating in excess of 20 percent refers to regulation of activities that is medically necessary to manage diabetes mellitus. There is no indication from the record that the Veteran was instructed to remain in a wheelchair in order to manage his disability. In addition, the evidence does not show that the Veteran was hospitalized for episodes of ketoacidosis or hypoglycemic reaction at any point, or that he required treatment from a diabetic care provider at least two times per month. Hence, as the Veteran does not meet the criteria for the next higher, 40 percent rating, he cannot meet the criteria for the next higher, 60 percent rating, as the criteria requires successive rating. See Tatum, supra. Moreover, the Veteran does not meet the other criteria required for a 60 or 100 percent rating, as the February 2013 VA examiner specifically noted the absence of any evidence that the Veteran has been hospitalized for episodes of ketoacidosis or hypoglycemic reaction at any point, or that he has required treatment from a diabetic care provider at least two times per month. Also, in accordance with Note (1), the Board has considered the complications of the Veteran’s diabetes mellitus, but finds that there is no basis for assignment of any separate, additional rating(s) for any such complications. In this regard, the Veteran already has been awarded a separate, compensable disability rating for erectile dysfunction. In evaluating the claim for an increased rating for the Veteran’s service-connected diabetes mellitus, the Board has considered both the Veteran and appellant’s assertions regarding his symptoms, which they are certainly competent to provide. See Layno, supra. However, as with most disabilities, here the criteria needed to support a higher rating for diabetes mellitus, or an additional separate rating, require medical findings that are within the province of trained medical professionals. See Jones, supra. Thus, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any higher, or additional, rating for diabetes mellitus, or its complications. For all the foregoing reasons, the Board finds that there is no basis for staged rating of the Veteran’s diabetes mellitus, and a higher rating is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine, but finds that the preponderance of the evidence is against assignment of any higher rating for diabetes mellitus at any point. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, supra. The claim is denied. Special Monthly Compensation – Aid and Attendance During his lifetime, the Veteran asserted that he was entitled to special monthly compensation because of the need of regular aid and attendance of another person due to his service-connected disabilities. In November 2013, he submitted an October 2013 examination for permanent need for regular aid and attendance to VA. As noted above, the Board has found that this application, which was submitted in tandem with a claim for an increased disability rating, has raised the issue and placed it properly before the Board. See Akles, supra. Generally, an award of special monthly compensation provides for additional levels of compensation above the basic levels of compensation afforded by the schedular rating criteria in 38 C.F.R. Part 4. These additional levels of compensation are awarded for various types of losses or levels of impairment, due solely to service-connected disabilities, and for specific combinations of such impairments. The different types of special monthly compensation available are commonly referred to by their alphabetic designations, such as (k), (l), etc., which correspond to the paragraphs of 38 U.S.C. § 1114 which provides the statutory authority for special monthly compensation benefits. These same paragraphs are codified in VA regulation predominantly at 38 C.F.R. § 3.350 (a) - (i). Special monthly compensation is payable at the aid and attendance rate specified under special monthly compensation (l) if a veteran has anatomical loss or loss of use of both feet, or loss of use of one hand and one foot; if he or she is blind or is so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less; if the veteran is a patient in a nursing home because of mental or physical incapacity; or if he or she is permanently bedridden or so helpless as to be in need of regular aid and attendance. 38 U.S.C. § 1114 (l); 38 C.F.R. § 3.350 (b). The benefit is also warranted if the evidence establishes a factual need for aid and attendance status under the criteria set forth in 38 C.F.R. § 3.352 (a). The following will be accorded consideration in determining the need for regular aid and attendance: inability of claimant to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid; inability of claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his or her daily environment. 38 C.F.R. § 3.352 (a). A veteran will be found to be “bedridden” if the condition actually requires that he remain in bed, but not if he voluntarily stays in bed or if a physician merely recommends bed rest. It is not required that all of the disabling conditions enumerated in this paragraph be found to exist before a favorable rating may be made. The particular personal functions that the veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that the veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Id. Determinations that the veteran is so helpless, as to be in need of regular aid and attendance will not be based solely upon an opinion that the claimant’s condition is such as would require him or her to be in bed. They must be based on the actual requirement of personal assistance from others. Id. The critical question to be determined is whether the Veteran’s service-connected disabilities resulted in the need for regular aid and attendance of another person because of resultant helplessness due to mental and/or physical impairment. The record here does not show, and the appellant does not allege, that the Veteran was blind or nearly blind or that he was a patient in a nursing home because of mental or physical incapacity. Likewise, he was not permanently bedridden as the record shows he was able to leave his bed to eat and bathe, and his house to attend medical appointments. In the October 2013 examination for housebound status, the Veteran’s treating physician determined that due to his service-connected disabilities, specifically due to the memory loss resulting from service connected adjustment disorder, the Veteran was unable to prepare his own meals (although he was able to feed himself) and needed assistance in dressing, bathing, and tending to hygiene needs. His wife had to administer his medication and she managed all finances. The Veteran’s memory and balance were poor and he fell asleep very easily. The Veteran left the house monthly or less, and only for medical appointments, and had to have a driver otherwise because he was not able to drive safely. The appellant testified in February 2021 that when he was alive, the Veteran was unable to dress himself or take a bath without aid. She had to help the Veteran use the restroom. He was unable to drive. The appellant noted that she reduced her hours at work, and eventually left her job, in order to take care of the Veteran and attend to his needs full-time. The appellant testified that, other than feeding himself, the Veteran had been unable to perform any task of daily living. Turning to the question of whether there is a factual need for aid and attendance, the Board observes that the Veteran has met the criteria set forth in 38 C.F.R. § 3.352 (a), and aid and attendance is warranted. Specifically, the evidence of record demonstrates that the Veteran was unable to dress or undress himself, or to keep himself ordinarily clean and presentable, without the assistance of another person. In addition, he was unable to attend to the wants of nature; and arguably required the care or assistance on a regular basis to protect him from dangers incident to his daily environment. Thus, the Board finds that the type of situation contemplated by the criteria for an award of special monthly compensation based on the need for the regular aid and attendance of another person have been met and that entitlement to special monthly compensation for this reason is warranted. 38 U.S.C. § 1114; 38 C.F.R. § 3.350 (b). The claim is granted. REASONS FOR REMAND The Veteran asserted before his death that he developed bilateral lower extremity neuropathy and that it was due to his service-connected diabetes mellitus, warranting service connection. In February 2013, the Veteran underwent a VA examination in relation to his claim. At that time, the Veteran reported experiencing intermittent tingling in his feet since 2009. On examination, he was found to have moderate bilateral lower extremity pain and mild paresthesias due to diabetic peripheral neuropathy. However, despite these findings, the examiner concluded that the Veteran did not have a diagnosis of diabetic peripheral neuropathy of the bilateral lower extremities. Further, the record documents multiple occasions during which the Veteran reported experiencing symptoms which could indicate the presence of peripheral neuropathy. For instance, in June 2015 he was seen at VA for hearing loss. At that time, it was noted that he had diabetic peripheral neuropathy which impacted his balance. A June 2016 treatment note indicated the Veteran was being treated with opioids for neuropathy in his feet. The Board may consider only independent medical evidence to support its findings and may not substitute its own unsubstantiated medical conclusions. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Thus, it finds that a new medical opinion is warranted. The February 2013 examiner both found that the Veteran had symptoms of diabetic neuropathy and did not. Because this examination is internally inconsistent, it is inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). In addition, the Veteran reported neuropathic symptoms and the record suggests a link to his service-connected diabetes mellitus. Thus, the Board finds that a remand is warranted. The matter is REMANDED for the following action: Provide the Veteran’s file to an appropriate examiner for review. Upon review of the whole record, to specifically include (but not limited to) the June 2015 and June 2016 records showing complaints of, and treatment for, bilateral neuropathy of the feet, the examiner is asked to determine whether the Veteran had a diagnosis of peripheral neuropathy of the bilateral lower extremities during his lifetime. If so, the examiner is asked to opine whether it is at least as likely as not (that is, a 50 percent chance or greater) that the Veteran’s peripheral neuropathy of the bilateral lower extremities was caused or aggravated by his service-connected diabetes mellitus. The examiner is asked to include a rationale with all opinions, citing to supporting clinical data/medical literature as appropriate. R. FEINBERG Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Jeremy J. Olsen, 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.