Citation Nr: 21031716 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 17-58 790 DATE: May 24, 2021 REMANDED Entitlement to service connection for diabetes mellitus is remanded. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to diabetes mellitus is remanded. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to diabetes mellitus is remanded. Entitlement to service connection for migraines is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a heart condition is remanded. Entitlement to service connection for a respiratory condition is remanded. Entitlement to service connection for a left knee disorder is remanded. Entitlement to service connection for a right knee disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from May 8, 1985 to May 31, 1985 before receiving a medical discharge under honorable conditions. Subsequently, he served in the Army National Guard from March 1988 to February 1996. His service in the Army National Guard included periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA), and active duty service in the Southwest Asia theater of operation from November 1990 to May 1991. In a January 2020 decision, the Board, among other things, denied the Veteran's claims seeking service connection for diabetes mellitus, hypertension, migraines, and peripheral neuropathy of the bilateral lower extremities. Subsequently, the Veteran appealed the denial of those claims in the January 2020 decision to the U.S. Court of Appeals for Veterans Claims (Court). In November 2020, the Court granted a Joint Motion for Remand (JMR), vacating the portion of the Board's decision that denied the Veteran's claims seeking service connection for diabetes mellitus, hypertension, migraines, and peripheral neuropathy of the bilateral lower extremities. The JMR did not address the Veteran's claims seeking service connection for a heart condition, a respiratory condition, and a bilateral knee disorder because those claims had been remanded by the Board in the January 2020 decision. The JMR instructed the Board to (i) obtain new adequate VA examinations considering the Veteran's migraines, diabetes mellitus, hypertension, and peripheral neuropathy of the bilateral lower extremities and (ii) ensure that VA 's duty to assist has been satisfied with treatment records from Dr. Christenson. 1. Entitlement to service connection for diabetes mellitus is remanded. 2. Entitlement to service connection for migraines is remanded. 3. Entitlement to service connection for hypertension is remanded. 4. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to diabetes mellitus is remanded. 5. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to diabetes mellitus is remanded. 6. Entitlement to service connection for a heart condition is remanded. 7. Entitlement to service connection for a respiratory condition is remanded. 8. Entitlement to service connection for a left knee disorder is remanded. 9. Entitlement to service connection for a right knee disorder is remanded. With respect to the Veteran's claims seeking service connection for diabetes mellitus, migraines, and hypertension, the November 2020 JMR directed the Board to remand those claims to obtain new VA examinations because the September 2017 VA examinations were inadequate. Specifically, the JMR instructed the Board that the new VA examinations should address whether the etiology and pathophysiology of his diabetes mellitus, migraines, and hypertension is known or unknown such that those disorders would qualify as undiagnosed illnesses or medically unexplained chronic multisymptom illnesses (MUCMI). See Stewart v. Wilkie, 30 Vet. App. 383, 392 (2018). Additionally, with respect to the Veteran's migraines, the JMR noted that the opinion of the September 2017 VA examiner was inadequate because it did not address his service treatment records, which indicated that the Veteran experienced headaches during active duty service in 1990. With respect to hypertension, the JMR noted that the opinion of the September 2017 VA examiner was inadequate because it again did not address his service treatment records that indicated hypertension in service and other in-service blood pressure readings at or near hypertensive levels, including May 1985, June 1988, July 1990 and July 1995 service treatment records. Accordingly, the Veteran's claims seeking service connection for diabetes mellitus, migraines, and hypertension must be remanded for new VA examinations because the September 2017 VA examinations are inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). With respect to the Veteran's claims seeking service connection for peripheral neuropathy of the left and right lower extremities, the JMR instructed the Board that a new VA examination was required because the September 2017 VA examination was inadequate. Specifically, the September 2017 VA examination was inadequate because the examiner failed to address treatment record documenting that the Veteran reported weakness and numbness in his right leg in 1985. Because the September 2017 VA examination was inadequate, the Veteran's claims seeking service connection for peripheral neuropathy of the left and right lower extremities must be remanded for a new VA examination considering the etiology of his peripheral neuropathy of the left and right lower extremities. Finally, the JMR indicates that the Board erred when it failed to ensure that all pertinent records from Dr. Christenson were obtained. The evidence currently includes treatment records from Dr. Christenson from April 2009 to October 2016, which reflect, among other things, treatment for or reports of symptoms of a heart condition, hypertension, diabetes mellitus, a bilateral knee disorder, and a respiratory condition. For example, an April 2009 treatment record reflects treatment for a heart condition, a June 2012 treatment record reflects treatment for a knee disorder, and a July 2016 treatment record reflects treatment for a respiratory condition. In February 2017, VA sent correspondence to the Veteran indicating that a second attempt was made to obtain treatment records from Dr. Christenson, and informing the Veteran that it was ultimately his responsibility to provide such records. As set forth in the JMR, because Dr. Christenson's treatment records from April 2009 and October 2016 and the February 2017 correspondence are both part of the record, it is unclear whether VA obtained all of Dr. Christenson's treatment records. Given that these treatment records relate to the Veteran's claims seeking service connection for a heart condition, a bilateral knee disorder, and a respiratory condition in addition to his claims seeking service connection for diabetes mellitus, migraines, hypertension, and peripheral neuropathy of the bilateral lower extremities, the Board is required to remand all of the Veteran's claims to ensure that the duty to assist has been satisfied with respect to Dr. Christenson's treatment records. The matters are REMANDED for the following action: 1. Provide the Veteran with VA Form 21-4142, Authorization and Consent to Release Information to VA, for any treatment that he may have received from Dr. Christenson at the McFarland Cardiology Clinic from November 2016 to the present. If a release is obtained, make reasonable efforts to obtain all identified records. If, after reasonable efforts have been made, the records cannot be obtained by VA, notify the Veteran and his representative. 2. Schedule the Veteran for VA examinations by an appropriate clinician, or clinicians, to determine the nature, extent, onset, and etiology of his diabetes mellitus, migraines, hypertension, peripheral neuropathy of the left lower extremity, and peripheral neuropathy of the right lower extremity. The claims file should be provided to the examiner(s) for review. All indicated studies deemed necessary by the examiner(s) should be performed, and all findings of those tests should be reported in detail. The examiner(s) should provide opinions as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's diabetes mellitus, migraines, hypertension, peripheral neuropathy of the left lower extremity, and peripheral neuropathy of the right lower extremity are etiologically related to the Veteran's period of active duty service. The examiner(s) also should address the following: Whether the Veteran's diabetes mellitus exhibits a disability pattern consistent with (i) an undiagnosed illness; (ii) a diagnosable but medically unexplained chronic multisymptom illness; (iii) a diagnosable chronic multisymptom illness with a partially explained etiology and pathophysiology; or (iv) a disease with a clear and specific diagnosis, etiology, and pathophysiology. Whether the Veteran's migraines exhibit a disability pattern consistent with (i) an undiagnosed illness; (ii) a diagnosable but medically unexplained chronic multisymptom illness; (iii) a diagnosable chronic multisymptom illness with a partially explained etiology and pathophysiology; or (iv) a disease with a clear and specific diagnosis, etiology, and pathophysiology. Whether the Veteran's hypertension exhibits a disability pattern consistent with (i) an undiagnosed illness; (ii) a diagnosable but medically unexplained chronic multisymptom illness; (iii) a diagnosable chronic multisymptom illness with a partially explained etiology and pathophysiology; or (iv) a disease with a clear and specific diagnosis, etiology, and pathophysiology. The term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Examples include, but are not limited to, the following: chronic fatigue syndrome; fibromyalgia; and functional gastrointestinal disorders. The response to this question should include a discussion of the pathophysiology of the Veteran's diabetes mellitus, migraines, and hypertension and/or reported symptomology of those disorders. Consideration of pathophysiology is a veteran-specific inquiry, as opposed to an inquiry regarding the general knowledge of the medical community. If the Veteran's disability pattern is consistent with either (iii) a diagnosable chronic multisymptom illness with a partially explained etiology and pathophysiology, or (iv) a disease with a clear and specific diagnosis, etiology, and pathophysiology, opine as to whether it is at least as likely as not (a 50 percent or greater probability) it was incurred in, or is otherwise related to service. In providing the foregoing opinions, the examiner(s) should address the relevant service treatment records, which reflect that he reported symptoms of or sought treatment for diabetes mellitus, migraines, hypertension, peripheral neuropathy of the left lower extremity, and peripheral neuropathy of the right lower extremity. These service treatment records include (i) an October 1990 treatment record reflecting that he reported headaches, (ii) a May 1985 treatment record reflecting that he reported right leg numbness, and (iii) May 1985, June 1988, July 1990, and July 1995 service treatment records that indicated hypertension or near hypertensive blood pressure readings. (Continued on the next page) If the examiner(s) cannot provide any of the requested opinions without resorting to speculation, he or she should provide an explanation stating why this is so. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). M. Pryce Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Crosnicker, 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.