Citation Nr: 21026324 Decision Date: 04/30/21 Archive Date: 04/30/21 DOCKET NO. 14-07 613 DATE: April 30, 2021 ORDER An initial rating in excess of 20 percent for DM is denied. An increased rating for right upper extremity peripheral neuropathy, evaluated as 20 percent disabling prior to September 22, 2016, and as 30 percent disabling thereafter, is denied. A rating in excess of 20 percent for left upper extremity peripheral neuropathy is denied. A rating in excess of 20 percent for left lower extremity peripheral neuropathy is denied. A rating in excess of 20 percent for right lower extremity peripheral neuropathy is denied. REMANDED Entitlement to service connection for hypertension (HTN), to include as secondary to service-connected diabetes mellitus, type II (DM) is remanded. FINDINGS OF FACT 1. The Veteran's DM requires the use of insulin and a restricted diet; the need for restricted activities has not been demonstrated. 2. Prior to September 22, 2016, the Veteran’s right upper extremity peripheral neuropathy resulted in no more than mild incomplete paralysis. 3. For the period beginning September 22, 2016, the Veteran’s right upper extremity peripheral neuropathy results in no more than moderate incomplete paralysis. 4. The Veteran’s left upper extremity peripheral neuropathy results in no more than moderate incomplete paralysis. 5. The Veteran’s left lower extremity peripheral neuropathy results in no more than moderate incomplete paralysis. 6. The Veteran’s right lower extremity peripheral neuropathy results in no more than moderate incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for DM have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.119, Diagnostic Code (DC) 7913 (2019). 2. Prior to September 22, 2016, the criteria for a rating in excess of 20 percent for right upper extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.124a, Diagnostic Code 8514. 3. For the period beginning September 22, 2016, the criteria for a rating in excess of 30 percent for right upper extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.124a, Diagnostic Code 8514. 4. The criteria for a rating in excess of 20 percent for left upper extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.124 a, Diagnostic Codes 8513 and 8514. 5. The criteria for a rating in excess of 20 percent for left lower extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.124a, Diagnostic Code 8520. 6. The criteria for a rating in excess of 20 percent for right lower extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.124a, Diagnostic Code 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1968 to July 1970. In January 2019, the Board remanded the case for further development by the originating agency. The case has been returned to the Board for further appellate action. In October 2020, the RO granted a TDIU effective September 22, 2016, on the basis of the Veteran's posttraumatic stress disorder (PTSD) and peripheral neuropathy. To date, the Veteran has not appealed the effective date of the grant of a TDIU. GENERAL RATING CRITERIA FOR INCREASED RATINGS Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. § Part 4 (2019). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1 (2019). 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2019). In both initial rating claims and normal increased rating claims, the Board must discuss whether any "staged ratings" are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the veteran. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 1. An initial rating in excess of 20 percent for DM Ratings for DM are governed by criteria and set forth in 38 C.F.R. § 4.119, DC 7913. A rating of 20 percent is assigned for DM requiring insulin and a restricted diet or an oral hypoglycemic agent and a restricted diet. A rating of 40 percent is assigned for DM requiring insulin, a restricted diet, and regulation of activities. A rating of 60 percent is assigned for DM requiring insulin, restricted diet, and regulation of activities and involving episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or visits to a diabetic care provider twice a month plus complications that would not be compensable if separately evaluated. A rating of 100 percent is assigned for diabetes mellitus requiring more than one daily injection of insulin, a restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) and involving 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, DC 7913. Noncompensable complications are considered part of the diabetic process under Code 7913. See Note 1 to Code 7913. The criteria for a 40 percent rating under DC 7913 are conjunctive not disjunctive-i.e. there must be insulin dependence and restricted diet and regulation of activities. "Regulation of activities" is defined by DC 7913 as the "avoidance of strenuous occupational and recreational activities." Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360 (2007). In a November 2015 rating decision, the RO granted service connection for DM. A 20 percent evaluation was assigned, effective December 13, 2012. The Veteran has appealed this initial rating. The medical evidence of record shows that throughout the appeal period, the Veteran's DM has required the use of hypoglycemic agents and a restricted diet, but there is no evidence that he has been advised to restrict his activities due to his disability. There is also no evidence of episodes of ketoacidosis or hypoglycemic reactions requiring one, two or three hospitalizations per year, visits to a diabetic care provider weekly or twice a month, or progressive loss of weight and strength. See May 2016 and October 2020 VA examination reports, and Birmingham VA Medical Center records dated from October 1988 to September 2019. In fact, the Veteran has not reported that he has been advised to restrict his activities due to his DM. See January 2016 notice of disagreement and July 2016 VA Form 9. Accordingly, a disability rating greater than 20 percent is not warranted for the Veteran's DM. 38 C.F.R. § 4.119, DC 7913. The Veteran is competent to report the symptoms of his DM. His complaints are credible. The Veteran's complaints have been considered in the above noted evidence; however, evaluations for VA purposes have not shown the severity required for a higher schedular rating, as discussed above. Additionally, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record with regards to this claim. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 2. An increased rating for right upper extremity peripheral neuropathy, evaluated as 20 percent disabling prior to September 22, 2016, and as 30 percent disabling thereafter 3. A rating in excess of 20 percent for left upper extremity peripheral neuropathy Here, the Veteran is in receipt of 20 and 30 percent ratings for peripheral neuropathy of the right upper extremities involving the radial nerve, pursuant to Diagnostic Code 8514. He is in receipt of 20 percent ratings for peripheral neuropathy of the left upper extremity for all radicular groups, pursuant to Diagnostic Code 8513. Neurologic impairments affecting all radicular groups are evaluated under Diagnostic Code 8513 (paralysis), 8613 (neuritis) and 8713 (neuralgia), using the criteria under Diagnostic Code 8513. Neurological impairments affecting the radial nerve are evaluated under Diagnostic Codes 8514 (paralysis), 8614 (neuritis) and 8714 (neuralgia), using the criteria under Diagnostic Code 8514. For diseases of the peripheral nerves, disability ratings are based on whether there is complete or incomplete paralysis of the particular nerve. The term “incomplete paralysis” 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. See 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves. When the involvement is wholly sensory, the rating should be for the mild, or at most the moderate degree. Id. Complete paralysis of the radial nerve is evidenced by the drop of hand and fingers, wrist and fingers perpetually flexed, the thumb abducted falling within the line of the outer border of the index finger, cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of wrist; supination of hand, extension and flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; or (very rarely) total paralysis of the triceps. 38 C.F.R. § 4.124a, Diagnostic Code 8514. Under Diagnostic Code 8513, for incomplete paralysis, a 20 percent disability rating is assigned for mild incomplete paralysis of the major and minor hand. A 30 percent disability rating is assigned for moderate incomplete paralysis of the minor hand and a 40 percent rating is assigned for moderate incomplete paralysis of the minor hand. If the condition is considered “severe,” a 60 percent disability rating is provided for the minor hand and a 70 percent rating is provided for the major hand. An 80 percent rating is warranted for complete paralysis of the minor hand and a 90 percent rating is warranted for complete paralysis of the major hand. Under Diagnostic Code 8514, for incomplete paralysis, a 20 percent disability rating is assigned for mild incomplete paralysis of the major and minor hand. A 30 percent disability rating is assigned for moderate incomplete paralysis of the major hand and a 20 percent rating is assigned for moderate incomplete paralysis of the minor hand. If the condition is considered “severe,” a 50 percent disability rating is provided for the major hand and a 40 percent rating is provided for the minor hand. A 70 percent rating is warranted for complete paralysis of the major hand and a 60 percent rating is warranted for complete paralysis of the minor hand. The Board observes that the words “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.” 38C.F.R. §4.6. The Veteran was initially examined in December 2016, in connection with his claim of entitlement to a higher rating for his service-connected DM. At that time, he complained of chronic, severe, tingling and burning in the bilateral hands. The VA examiner noted constant, moderate pain and moderate paresthesias and/or dysesthesias in the upper extremities bilaterally. Light touch and vibration sensation were also decreased. However, strength and reflexes were normal in the upper extremities, and there was no muscle atrophy. The examiner diagnosed mild peripheral neuropathy of the upper extremities, affecting the radial and median nerves. The Veteran was examined again for his peripheral neuropathy in January 2019. The examiner noted constant, mild pain and mild paresthesias and/or dysesthesias in the upper extremities bilaterally. Light touch was decreased in the upper extremities, but there were no trophic changes and no muscle atrophy and strength and reflexes were normal in the upper extremities. The Veteran was diagnosed with mild peripheral neuropathy of the upper extremities, affecting the radial nerve. The Veteran was examined most recently for his peripheral neuropathy in October 2020. He complained of increased pain, numbness and tingling in the hands. The examiner noted constant, severe pain, moderate paresthesias and/or dysesthesias, and moderate numbness in the upper extremities bilaterally. Muscle strength was slightly decreased to 4/5 in the upper extremities for grip and pinch, but reflexes were normal and there was no muscle atrophy. The Veteran was diagnosed with moderate peripheral neuropathy of the upper extremities, affecting the radial nerve. The VA treatment records dated throughout the appeals period support the findings included in the VA examinations. The Board finds that prior to September 22, 2016, the radiculopathy of the right and left upper extremities is best rated as mild and a higher rating is not warranted. 38 C.F.R. § 4.124 a, Diagnostic Code 8514. There is no clinical evidence of record to suggest that he had moderate radiculopathy of the major (right) upper extremity during that period, as is required for the next higher rating of 30 percent under Diagnostic Code 8514. In this regard, the Board notes that, at no time prior to September 22, 2016, did the Veteran present symptoms on objective examination approaching this level of severity for the right upper extremity. Specifically, during all of the VA examinations, the Veteran had essentially normal or only slightly reduced muscle strength and no muscle atrophy. Additionally, there is no evidence of complete drop of the hands and fingers, supination of the hand, or total paralysis of the triceps at any point during this period. The Board further finds that for the period beginning September 22, 2016, the radiculopathy of the right upper extremity is best rated as moderate and a higher rating is not warranted. 38 C.F.R. § 4.124 a, Diagnostic Code 8514. Although the Although the Veteran reported on VA examination in 2016 that he experienced chronic, severe, tingling and burning in the bilateral hands, and in 2020 increased pain, numbness and tingling in the hands, there is no clinical evidence of record to suggest that he has severe radiculopathy of the major (right) upper extremity, as is required for the next higher rating of 50 percent. In this regard, the Board notes that, at no time has the Veteran presented symptoms on objective examination approaching this level of severity for the right upper extremity. Specifically, during the most recent VA examination in 2020, the Veteran reported experiencing severe pain in the upper extremities, which is accounted for in his increased rating of 30 percent. Nevertheless, during all of the VA examinations, including in 2020, the Veteran has still had essentially normal or only slightly reduced muscle strength and no muscle atrophy. Additionally, there is no evidence of complete drop of the hands and fingers, supination of the hand, or total paralysis of the triceps at any point during this period. The Board finds that for the entire period on appeal, the radiculopathy of the left upper extremity is best rated as mild and a higher rating is not warranted. 38 C.F.R. § 4.124 a, Diagnostic Codes 8513 and 8514. Although the Veteran reported on VA examination in 2016 that he experienced chronic, severe, tingling and burning in the bilateral hands, and in 2020 increased pain, numbness and tingling in the hands, there is no clinical evidence of record to suggest that he had severe radiculopathy of the minor (left) upper extremity during that period, as is required for the next higher rating of 40 percent under Diagnostic Code 8514. In this regard, the Board notes that, at no time has the Veteran presented symptoms on objective examination approaching this level of severity for the left upper extremity. Specifically, during all of the VA examinations, the Veteran had normal or only slightly reduced muscle strength and no muscle atrophy. Additionally, there is no evidence of complete drop of the hands and fingers, supination of the hand, or total paralysis of the triceps at any point during this period. The Board also notes that although the Veteran has been rated under Diagnostic Code 8513 for the left upper extremity, a rating in excess of 30 percent under that code is still not warranted. In this regard, the December 2016 VA examiner noted that there was evidence of incomplete paralysis in the median nerve as well as the radial nerve of the upper extremities. However, the examiner only diagnosed mild incomplete paralysis in the radial and median nerves. Therefore, a rating in excess of 20 percent is not warranted under Diagnostic Code 8513, for all radicular groups. Additionally, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record with regards to these claims. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 4. A rating in excess of 20 percent for left lower extremity peripheral neuropathy 5. A rating in excess of 20 percent for right lower extremity peripheral neuropathy Here, the Veteran is in receipt of a 20 percent rating for peripheral neuropathy of the left and right lower extremities involving the sciatic nerve, pursuant to Diagnostic Code 8520. Neurological impairments affecting the sciatic nerve are evaluated under Diagnostic Codes 8520 (paralysis), 8620 (neuritis) and 8720 (neuralgia), using the criteria under Diagnostic Code 8520. For diseases of the peripheral nerves, disability ratings are based on whether there is complete or incomplete paralysis of the particular nerve. The term “incomplete paralysis” 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. See 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves. When the involvement is wholly sensory, the rating should be for the mild, or at most the moderate degree. Id. Complete paralysis of the sciatic nerve is evidenced by the foot dangled and dropped, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Under Diagnostic Code 8520, for incomplete paralysis, a 10 percent disability rating is assigned for mild incomplete paralysis. A 20 percent disability rating is assigned for moderate incomplete paralysis. If the condition is considered “moderately severe,” a 40 percent disability rating is provided, and a 60 percent rating is warranted for conditions considered “severe, with marked muscular atrophy.” The Board observes that the words “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.” 38C.F.R. §4.6. The Veteran was initially examined in December 2016, in connection with his claim of entitlement to a higher rating for his service-connected DM. At that time, he complained of foot pain, worse with prolonged walking and standing. The VA examiner noted constant, moderate pain and moderate paresthesias and/or dysesthesias in the lower extremities bilaterally. Light touch and vibration sensation were also decreased. The examiner also noted trophic changes—smooth, hairless legs bilaterally. However, muscle strength was normal, reflexes were normal except for a slight decrease in the right knee and the ankles, and there was no muscle atrophy. The examiner diagnosed moderate peripheral neuropathy of the lower extremities, affecting the sciatic nerve. The Veteran was examined again for his peripheral neuropathy in January 2019. He reported increased pain in his feet, somewhat improved with medication. The examiner noted constant, moderate pain and moderate paresthesias and/or dysesthesias in the lower extremities bilaterally. Cold sensation was decreased in the lower extremities, but there were no trophic changes and no muscle atrophy, muscle strength was normal, and reflexes were normal except for a slight decrease in the ankles. The Veteran was again diagnosed with moderate peripheral neuropathy of the lower extremities, affecting the sciatic nerve. The Veteran was examined most recently for his peripheral neuropathy in October 2020. He complained of increased pain, numbness and tingling in the feet. The examiner noted constant, severe pain, moderate paresthesias and/or dysesthesias, and moderate numbness in the lower extremities bilaterally. Muscle strength was slightly decreased to 4/5 in the lower extremities for the ankles, but reflexes were normal, and there was no muscle atrophy. The Veteran was diagnosed with moderate peripheral neuropathy of the upper extremities, affecting the sciatic nerve. VA treatment records dated throughout the appeals period support the findings included in the VA examinations. The Board finds that the radiculopathy of the right and left lower extremities is best rated as moderate and a higher rating is not warranted. 38 C.F.R. § 4.124 a, Diagnostic Code 8520. Although the Veteran reported on VA examination in 2016 that he experienced severe pain, tingling and burning in his feet and in 2019, increased bilateral foot pain, there is no clinical evidence of record to suggest that he has moderately severe right or left lower extremity radiculopathy, as is required for the next higher rating of 40 percent. In this regard, the Board notes that, at no time during the appeal, did the Veteran present symptoms on objective examination approaching this level of severity. Specifically, during all of the VA examinations, the Veteran had normal or only slightly reduced muscle strength and no muscle atrophy. Additionally, there is no evidence of foot paralysis at any point during the appeals period. In reaching the above conclusions, the Board has not overlooked the Veteran’s statements with regard to the severity of his bilateral upper and lower extremity radiculopathy. In this regard, the Veteran is competent to report on factual matters of which he had firsthand knowledge, e.g., experiencing severe pain in his legs and hands. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Veteran has provided lay evidence, through written statements and reports made during VA examinations, with respect to the presence of pain and the severity of such. He is competent to provide such statements, and the Board finds that the Veteran’s statements are credible. Moreover, the Board has considered the Veteran’s reports with respect to pain in evaluating his assigned ratings. With respect to the Rating Schedule, the criteria set forth therein generally require medical expertise where the types of findings required are not readily observable by a lay person. Therefore, the objective medical findings provided by the Veteran’s VA examination reports have been accorded greater probative weight. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (“[t]he probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches... the credibility and weight to be attached to these opinions [are] within the province of the adjudicator.”). As a preponderance of the evidence is against the award of higher ratings for the right and left lower and upper extremity radiculopathy, the benefit-of-the-doubt doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). Additionally, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record with regards to these claims. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND 1. Entitlement to service connection for hypertension (HTN), to include as secondary to service-connected diabetes mellitus, type II (DM) is remanded. In its January 2019 remand, the Board directed that the Veteran be afforded another VA examination and medical opinion addressing the etiology of his claimed HTN. The Board specifically directed the examiner to provide an opinion as to whether it is at least as likely as not that the Veteran’s HTN is related to his confirmed in-service herbicide exposure. In answering this question, the examiner was asked to disregard whether the disorder is one for which a “presumption” has been established and, instead, to answer whether the Veteran’s HTN is a result of Agent Orange exposure even though it is not on the list of “presumptive” diseases. The Board also directed that the opinion include consideration and discussion of the Veteran’s presumed exposure to herbicide agents, as well as the National Academy of Sciences Institute of Medicine (NAS) study and article, which concluded that there is “limited or suggestive evidence of an association” between herbicide exposure and hypertension. See 77 Fed. Reg. 47924, 47926-927 (Aug. 10, 2012). The examiner was also directed to opine as to whether the Veteran’s HTN was caused or aggravated by his service-connected DM. A VA medical opinion was submitted in October 2020. The examiner concluded that the claimed HTN was less likely than not incurred in or caused by the Veteran’s active service. The only rationale given was that the onset of the Veteran’s HTN was more than 25 years after service, and that HTN has not definitely been found to be caused by exposure to herbicides. The examiner’s opinion, although stated differently, essentially says that HTN has not been determined to be a presumptive disease for service connection based on herbicide exposure. The examiner did not give any other reasoning for why the Veteran’s HTN is not related to his Agent Orange exposure. Furthermore, the examiner failed to discuss the NAS study and article discussing evidence of an association between HTN and Agent Orange, as directed by the Board. The examiner also opined that the Veteran’s HTN was not caused by his service-connected DM, but the examiner failed to discuss whether his HTN was aggravated by his DM. When VA undertakes to provide a VA examination or obtain a VA opinion it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Furthermore, the Board is under a duty to ensure compliance with the terms of its prior remands. Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where the remand orders of the Board or the Court are not complied with, the Board errs as a matter of law when it fails to ensure compliance, and further remand will be mandated). As such, and for all the reasons noted above, the Board finds that another remand is required to obtain an addendum medical opinion in compliance with the Board's January 2019 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). By this remand, the Board makes no determination, express or implied, concerning the credibility of any lay statements on file. The matters are REMANDED for the following action: 1. Send the Veteran's claims file to an appropriate medical professional, other than the examiner who rendered the opinion in October 2020, to obtain an opinion regarding the nature and etiology of the currently diagnosed hypertension. The record, to include a copy of this remand, must be made available to and be reviewed by the examiner. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. Thereafter, the examiner is to provide opinions as to: 2. Whether it is at least as likely as not (50 percent or higher probability) that the Veteran’s hypertension had onset during service or within one year of discharge from service or is otherwise related to service. 3. Whether it is at least as likely as not (50 percent or higher probability) that the Veteran’s hypertension is related to his confirmed in-service herbicide exposure. In answering this question, the examiner is asked to disregard whether the disorder is one for which a “presumption” is established and, instead, to answer whether the Veteran’s hypertension is a result of Agent Orange exposure even though it is not on the list of “presumptive” diseases. The opinion should include consideration and discussion of the Veteran’s presumed exposure to herbicide agents as well as the NAS study and the above-referenced article regarding Agent Orange and hypertension. 4. Whether it is at least as likely as not (50 percent or higher probability) that the Veteran’s hypertension is caused by his service-connected diabetes mellitus, type 2. 5. Whether it is it at least as likely as not (50 percent or higher probability) that the Veteran’s hypertension is aggravated by his service-connected diabetes mellitus, type 2. “Aggravation” is an increase in disability beyond the natural progress of the disease or temporary flare-up. A detailed rationale for all opinions expressed should be provided. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 2. After completion of the above and any other development deemed necessary, review the expanded record and readjudicate the Veteran's claim for service connection. If the benefit sought on appeal is not granted, the Agency of Original Jurisdiction should issue a supplemental statement of the case and provide the appropriate opportunity to respond, before returning the case to the Board, if otherwise in order. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board F. Yankey, 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.