Citation Nr: 21026927 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 16-04 188 DATE: May 4, 2021 ORDER Service connection for residuals of a cerebrovascular accident (CVA) is granted. REMANDED Entitlement to a rating in excess of 50 percent for posttraumatic stress with alcohol abuse (PTSD) for the period prior to November 15, 2017 is remanded. Entitlement to a rating in excess of 70 percent for PTSD for the period starting November 15, 2017 is remanded. Entitlement to a rating in excess of 20 percent for diabetes mellitus, type 2 (diabetes) with left hand carpal tunnel syndrome is remanded. Entitlement to a rating in excess of 10 percent for right lower extremity peripheral neuropathy for the period prior to April 8, 2020 is remanded. Entitlement to a rating in excess of 10 percent for left lower extremity peripheral neuropathy for the period prior to April 8, 2020 is remanded. Entitlement to a rating in excess of 20 percent for right lower extremity peripheral neuropathy for the period starting April 8, 2020 is remanded. Entitlement to a rating in excess of 20 percent for left lower extremity peripheral neuropathy for the period starting April 8, 2020 is remanded. FINDING OF FACT The Veteran's diagnosed CVA is, at least in part, secondary to his service-connected PTSD with alcohol abuse disability. CONCLUSION OF LAW The criteria to establish entitlement to service connection for residuals of a CVA as secondary to the service-connected PTSD with alcohol abuse disorder are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from August 1965 to June 1969, to include service in the Republic of Vietnam. These matters are before the Board of Veterans' Appeals (Board) on appeal from a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). These matters were last before the Board in June 2020, when they were remanded for additional development. The Board notes that the Veteran requested a Board hearing. However, he did not report for his hearing scheduled in June 2019 and has not requested that it be rescheduled. Thus, his hearing request is deemed to be withdrawn. 38 C.F.R. § 20.704(d) (2020). Service Connection for Residuals of a CVALaws and Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Only chronic diseases listed under 38 C.F.R. § 3.309 (a) are entitled to the presumptive service connection provisions of 38 C.F.R. § 3.303 (b). Walker v. Shinseki, 708 F.3d 1331 Fed. Cir. 2013). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310 (a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310 (a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Initially, the Board finds that the Veteran has a history of a CVA, with residual symptoms of mild weakness to the left side. See April 2020 VA treatment record. Next, the Veteran has been awarded service connection for PTSD with alcohol abuse disorder and diabetes, among other disabilities. The Board further finds that the evidence is at least in equipoise as to whether the Veteran's residuals of a CVA were (either caused or aggravated by) his service-connected disabilities. VA treatment records from February 2013 specifically indicate that the Veteran's risk factors for a CVA included his insulin dependent diabetes and alcohol abuse, both service-connected disabilities. An April 2010 treatment record "suspected that alcohol was a factor" in the Veteran's CVA. A VA medical opinion was obtained in August 2020. The examiner opined that the Veteran's CVA was less likely than not due to the Veteran's service-connected disabilities because CVAs were caused by a blockage in the brain or an embolus from the heart and were not etiologically related to any of his service-connected disabilities. However, the examiner's rationale did not acknowledge or address the treatment records discussed above. The Board notes that in Ward v. Wilkie, the United States Court of Appeals for Veterans Claims held that, for secondary service connection, "aggravation" need not be permanent in nature. 31 Vet. App. 233, 241-42 (2019). For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds the criteria to establish service connection for residuals of a CVA as secondary to the service-connected diabetes and psychiatric disabilities are met. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The appeal is granted. REASONS FOR REMAND 1. Entitlement to a rating in excess of 50 percent for PTSD for the period prior to November 15, 2017 is remanded. 2. Entitlement to a rating in excess of 70 percent for PTSD for the period starting November 15, 2017 is remanded. 3. Entitlement to a rating in excess of 20 percent for diabetes with left hand carpal tunnel syndrome is remanded. 4. Entitlement to a rating in excess of 10 percent for right lower extremity peripheral neuropathy for the period prior to April 8, 2020 is remanded. 5. Entitlement to a rating in excess of 10 percent for left lower extremity peripheral neuropathy for the period prior to April 8, 2020 is remanded. 6. Entitlement to a rating in excess of 20 percent for right lower extremity peripheral neuropathy for the period starting April 8, 2020 is remanded. 7. Entitlement to a rating in excess of 20 percent for left lower extremity peripheral neuropathy for the period starting April 8, 2020 is remanded. The evidence indicates there may be outstanding relevant VA treatment records. VA treatment records from August 5, 2019 and April 14, 2019 indicate that the Veteran was to return for follow up appointments in July 2020 and August 2020. VA treatment records dated after April 14, 2020 have not been associated with the claims file. A remand to obtain the outstanding records is required. The record indicates that there are outstanding private treatment records. VA treatment records from October 17, 2016 indicate that the Veteran received diabetic management from a non-VA provider, Dr. Garett. Likewise, an April 8, 2020 VA record noted that the Veteran received private treatment from Dr. Magalucy, Dr. Marinini, and Dr. Wolcott. To date, these records have not been obtained. On remand, reasonable efforts should be made to obtain them. The June 2020 remand also requested a VA examination to address the severity of the Veteran's diabetes with left carpal tunnel syndrome. The Veteran was afforded diabetes, diabetic peripheral neuropathy, and central nervous system examinations in August 2020. Nevertheless, further clarification is required as the examiner's findings, even taken in combination, do not clearly indicate the severity of the Veteran's service-connected carpal tunnel syndrome. Specifically, while the diabetic peripheral neuropathy examination indicated that the Veteran's left upper extremity symptoms were due to carpal tunnel syndrome, the examiner did not identify the impacted nerves or state whether the symptoms were productive of mild, moderate, or severe incomplete paralysis. Additionally, the same examiner appeared to contradict that finding in the central nervous system examination wherein she stated that the Veteran's mild left upper extremity weakness was due to his CVA residuals rather than his carpal tunnel syndrome. While an addendum opinion was obtained in December 2020, the examiner only addressed generalities of the comorbid conditions and did not clarify which symptoms were attributable to the Veteran's carpal tunnel syndrome and which were due to his status post CVA or identify the nerves affected by the carpal tunnel syndrome. Accordingly, another addendum opinion is required. The matters are REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities, including Dr. Garett, Dr. Magalucy, Dr. Marinini, and Dr. Wolcott. After securing any necessary releases, the AOJ should request any relevant records identified. In addition, obtain updated VA treatment records dated since April 14, 2020. If any requested records are unavailable, the Veteran should be notified of such. 2. After the above record development is completed to the extent possible, forward the claims file to a VA clinician to obtain an addendum opinion regarding the Veteran's carpal tunnel syndrome, to include any residual neurological symptoms associated with his now service-connected CVA disability. If an examination is deemed necessary to respond to the questions, one should be scheduled. Following review of the claims file, the clinician should identify all symptoms attributable to the Veteran's left carpal tunnel syndrome or any residual neurological symptoms associated with his now service-connected CVA disability, identify the nerves affected, state whether the disability causes complete or incomplete paralysis, and provide an opinion as to the severity of any such paralysis. A complete rationale should be provided for all opinions and conclusions expressed. 3. Then, readjudicate the claims on appeal. Romina A. Casadei Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Anderson 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.