Citation Nr: 21028027 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 13-28 277A DATE: May 10, 2021 REMANDED Entitlement to service connection for bilateral upper extremity neuropathy, to include as secondary to service-connected diabetes mellitus, type II, or due to service in Southwest Asia, is remanded. REASONS FOR REMAND The Veteran served honorably on active duty in the U.S. Army from April 1977 to April 1980, March 1981 to February 1983, and November 1990 to January 1992, to include service in Southwest Asia. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a June 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This matter was remanded by the Board in January 2018 and February 2020. In a March 2021 rating decision, the RO granted service connection for diabetes mellitus, diabetic neuropathy of the lower extremities, and diabetic retinopathy effective August 11, 2010. The Veteran has not expressed disagreement with the evaluations or effective dates assigned in the March 2021 rating decision, and it is a full grant as to those benefits sought on appeal. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). The remaining issue on appeal has been returned for appellate review. Entitlement to service connection for bilateral upper extremity neuropathy, to include as due to diabetes mellitus is remanded. This issue is remanded to obtain clarification as to whether neuropathy of the upper extremities has been present at any point during the appeal period, and if so, what the etiology of those symptoms is. A February 1999 VA examination report records the Veteran's testimony of hand numbness since 1991 when she was stationed in Southwest Asia. The impression was numbness in the extremities. A March 1999 VA examination report documents the Veteran's complaints of intermittent numbness and coldness in the hands. The examiner found there was no evidence at that time for diabetic neuropathy, and noted the Veteran's complaints were intermittent and not particularly prominent. On examination, there was mild decrease in vibration in the right knuckle. If the Veteran did have diabetic neuropathy, the examiner explained it was in the very early stages. The Veteran submitted a private medical report dated September 2013 that notes symptoms of numbness, tingling, and sensitivity or pain in the hands. The medical provider wrote that the skin sensation changes could be associated with fibromyalgia. The Veteran underwent a VA examination in October 2020. That examiner reported the Veteran had numbness in her feet since 1991 that had improved over time. The examiner did not report any history of upper extremity symptoms despite the indication of symptoms in the record. Even if the Veteran's neuropathy symptoms of the upper extremities had resolved by the time of the October 2020 examination, service-connection may be granted for a disability that manifested at any time during the appeal period, regardless of whether the symptoms later resolved. McClain v. Nicholson, 21 Vet. App. 319 (2007). On remand, clarification is necessary regarding whether the Veteran had neuropathy of the upper extremities during the appeal period, and if so, the examiner should provide an opinion on the etiology of those symptoms. The matters are REMANDED for the following action: 1. Obtain an addendum opinion regarding the nature and etiology of any upper extremity neurological symptoms from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. (a.) Clarify whether the Veteran has had a neurological disorder of the upper extremities at any point since 2010. (b.) Identify the Veteran's objective indications of a disability. "Objective indications" of a qualifying chronic disability include both objective evidence perceptible to an examining physician and other non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). (c.) By history, physical examination, or laboratory testing, can the Veteran's objective indications of a disability be attributed to a known clinical diagnosis, to include diabetic neuropathy? If the signs and symptoms are not characteristic of a known clinical diagnosis, the examiner should so indicate. There is no requirement that the examiner provide a diagnosis of undiagnosed illness. (d.) If the Veteran's objective indications cannot be attributed to a known clinical diagnosis, is there affirmative evidence that the undiagnosed illness is not incurred during active service during the Persian Gulf War or that it was caused by a supervening condition or event that occurred since the Veteran's departure from service during the Persian Gulf War? The examiner should note that a positive response to this question requires affirmative evidence. The mere absence of evidence is not sufficient. (e.) If the Veteran's objective indications can be attributed to a known clinical diagnosis, is the etiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood? This determination as to each must be based on the Veteran's specific case and cannot be based on the etiology of the disease or disability population as a whole. (f.) If the Veteran's objective indications can be attributed to a known clinical diagnosis, is the pathophysiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood? This determination as to each must be based on the Veteran's specific case and cannot be based on the pathophysiology of the disease or disability population as a whole. (g.) If both the etiology and pathophysiology are partially understood or fully understood, then is it at least as likely as not (a 50 percent or greater probability) that the Veteran's diagnosed condition was incurred in, or is otherwise related to, active service? (h.) The examiner must specifically address the following: 1) A February 1999 VA examination report noting testimony of hand numbness since 1991 with an impression of numbness in the extremities; 2) a March 1999 VA examination report documenting the Veteran's complaints of intermittent numbness and coldness in the hands, and objective findings of mild decrease in vibration in the right knuckle; and 3) a private medical report dated September 2013 that notes symptoms of numbness, tingling, and sensitivity or pain in the hands and an assessment that the skin sensation changes could be associated with fibromyalgia. SCOTT W. DALE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Smith, 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.