Citation Nr: 21023169 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 12-32 646 DATE: April 20, 2021 REMANDED Entitlement to service connection for chronic inflammatory demyelinating polyneuropathy (CIDP) of the left upper extremity, to include as secondary to service connected diabetes mellitus, is remanded. Entitlement to service connection for CIDP of the left lower extremity, to include as secondary to service connected diabetes mellitus, is remanded. Entitlement to service connection for hypertension, to include as secondary to service connected diabetes mellitus, and to include as due to herbicide agent exposure, is remanded. Entitlement to service connection for chronic urinary tract infections or hematuria, to include as secondary to service connected diabetes mellitus, is remanded. Entitlement to service connection for a skin disorder, to include as secondary to his service connected diabetes mellitus, is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1965 to July 1967, to include service in the Republic of Vietnam. Regrettably, the Veteran died in October 2013. The appellant is his surviving spouse. These matters come to the Board of Veterans’ Appeals (Board) on appeal from a December 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) Pittsburgh, Pennsylvania. Jurisdiction of this appeal is currently with the RO in Houston, Texas. In September 2017, the Board issued a decision denying entitlement to service connection for CIDP of the left upper extremity, CIDP of the left lower extremity, hypertension, chronic urinary tract infections or hematuria, and a skin disorder. The Veteran subsequently appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In an October 2018 Order, the Court issued a Memorandum Decision and remanded the case to the Board for action consistent with the Memorandum Decision. This case was most recently before the Board in April 2020, at which time the appeal was remanded to the Agency of Original Jurisdiction (AOJ) for further development. The case has now been returned to the Board for appellate action. 1. Service Connection – CIDP and Hypertension The appellant seeks entitlement to service connection for CIDP and hypertension, to include as secondary to the Veteran’s service-connected diabetes mellitus. As noted above, the claims were most recently before the Board in April 2020, when the claims were remanded to the AOJ for further development. Specifically, the April 2020 Board remand directed the AOJ to obtain an additional VA opinion with respect to whether the Veteran’s CIDP and hypertension were aggravated by his service connected diabetes mellitus, which was due to his herbicide agent exposure. The April 2020 Board sought opinions regarding secondary service connection addressing aggravation. It its remand directives, the April 2020 Board remand directed AOJ to obtain an addendum opinion to determine whether the Veteran’s CIPD and/or hypertension were aggravated by the service-connected diabetes mellitus (aggravation: increase in severity beyond the natural progress of the disease); and provide a complete rationale for his or her opinions in the report. The addendum VA opinion was obtained in November 2020. At that time, with regard to CIDP, the examiner opined that the Veteran’s CIDP was less likely than not proximately due to or the result of the Veteran’s service-connected condition and was not aggravated beyond its natural progression by diabetes mellitus. In this regard, the examiner noted that CIDP is an autoimmune disease with onset on the Veteran’s left side, that the process had its own characteristic pattern until the Veteran’s death in 2013, that there was no data for any aggravation by his service-connected diabetes mellitus, that his diabetes was only controlled by his diet and that there was no severity or longevity for the diabetes mellitus to impact CIDP. With regard to hypertension, the November 2020 VA examiner opined that the Veteran’s hypertension was less likely than not aggravated beyond its natural progression by his service-connected diabetes mellitus. In that regard, the examiner noted that there was no diabetes mellitus longevity, or loss of control, or direct etiology for his hypertension to be “other than essential in nature,” and; obstructive nephropathy already caused renal disease early on in in the 2000s, but no separate low level diabetes since the 2000s was plausible for a nexus for etiology or permanent aggravation. Additionally, the examiner found that essential hypertension is the only proper diagnosis, and there is no nexus to diabetes mellitus shown. The Board finds the November 2020 opinions incomplete to decide the claims. In this regard, the examiner did not provide supporting or adequate rationale for the conclusions reached. Namely, the examiner provided conclusory statements that the conditions were not aggravated by diabetes mellitus. Given these deficiencies, the Board is unable to find that substantial compliance with the prior remand has been achieved. See D’Aries, 22 Vet. App. at 105; see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999). As such, remand is again to obtain VA opinions that complies with the Board’s prior remand directives. See Stegall v. West, 11 Vet. App. at 268, 271 (1998). 2. Service Connection – Chronic Urinary Tract Infections and a Skin Disorder Regarding the issues of entitlement to service connection for chronic urinary tract infections and a skin disorder, the Board notes that the issues are inextricably intertwined with the claims remanded herein. Harris v. Derwinski, 2 Vet. App. 180, 183 (1991). As noted in the April 2020 Board remand, the January 2020 VA examiner explicitly stated that the Veteran’s chronic urinary tract infections and hematuria were secondary to the Veteran’s CIDP and that the immobility caused by his CIDP resulted in recurrent skin pressure ulcers. Hence, a determination on the claims for entitlement to service connection for chronic urinary tract infections and a skin disorder should be deferred pending final dispositions of the claims of entitlement to service connection for CIDP and hypertension. The matters are REMANDED for the following action: 1. Obtain an addendum VA opinion from the VA examiner who conducted and provided the November 2020 VA examination and opinion regarding the Veteran’s CIDP and hypertension. Following a review of the record, the examiner is again asked to address the following: Is it at least as likely as not (50 percent or more probability) that the CIDP and/or hypertension was permanently aggravated beyond its natural progression by service-connected diabetes mellitus? If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). If the inability to provide an opinion without resorting to speculation is due to a deficiency in the record (additional facts are required), the AOJ should develop the claim to the extent it is necessary to cure any such deficiency. If the inability to provide an opinion is due to the examiner’s lack of requisite knowledge or training, then the AOJ should obtain an opinion from a medical professional who has the knowledge and training needed to render such an opinion. A CLEAR RATIONALE FOR ALL OPINIONS IS REQUIRED. 2. Thereafter, readjudicate the claims. If any benefit sought on appeal remains denied, furnish the appellant and her representative a supplemental statement of the case and allow an appropriate period of time to respond. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mariah N. Sim, 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.