Citation Nr: 21032038 Decision Date: 05/25/21 Archive Date: 05/25/21 DOCKET NO. 16-44 705 DATE: May 25, 2021 ORDER An evaluation in excess of 20 percent disabling for type 2 diabetes mellitus is denied. Service connection for peripheral neuropathy, left upper extremity, as secondary to the service-connected disability of diabetes mellitus type II is denied. Service connection for peripheral neuropathy, right upper extremity, as secondary to the service-connected disability of diabetes mellitus type II is denied. Service connection for irritable bowel syndrome as secondary to the service-connected disability of posttraumatic stress disorder or medication taken for diabetes mellitus type II is denied. Service connection for Bell's palsy as secondary to the service-connected disability of diabetes mellitus type II is granted. Service connection for hypertension as secondary to the service-connected disability of diabetes mellitus type II is granted. REMANDED Entitlement to an evaluation of total disability based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's type 2 diabetes mellitus manifested as requiring at least daily insulin shots, prescribed oral hypoglycemic agent, and restricted diet. 2. The preponderance of evidence does not support that the Veteran had a diagnosis of left upper extremity neuropathy for which service connection may be granted. 3. The preponderance of evidence weighs against a finding that the Veteran's right upper extremity neuropathy was proximately caused or aggravated by a service-connected disability. 4. The preponderance of evidence does not support that the Veteran had a diagnosis of irritable bowel syndrome or any other gastrointestinal condition for which service connection may be granted proximate to or during the period on appeal. 5. The evidence is at least in equipoise that the Veteran's Bell's palsy condition was proximately due to by his service-connected diabetes mellitus. 6. The preponderance of evidence supports a finding that the Veteran's hypertension was aggravated by his service-connected diabetes mellitus. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 20 percent for diabetes mellitus are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.119, Diagnostic Code 7913. 2. The criteria for service connection for left upper extremity neuropathy due to service or service-connected diabetes mellitus are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for service connection for right upper extremity neuropathy due to service or service-connected diabetes mellitus are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for irritable bowel syndrome due to service or a service-connected disability are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. 5. The criteria for service connection for Bell's palsy as secondary to service-connected diabetes mellitus are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310(a). 6. The criteria for service connection for hypertension as secondary to service-connected diabetes mellitus are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310(b). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from June 1971 to June 1974. He record the Combat Infantry Badge. The Veteran died in April 2019. The appellant is the Veteran's surviving spouse. This appeal comes before the Board of Veterans' Appeals (Board) from a January 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. In June 2020, the appellant testified at a videoconference hearing from Glendale, Oregon, before the undersigned Veterans Law Judge. A transcript of the hearing is available in the record. An August 2016 statement of the case denied, among other issues, service connection for a vision disability (claimed as retinopathy). The following month the Veteran submitted a VA Form 9 and checked box 8A which limited his appeal to the listed issues. As the Veteran did not list the vision issue, an appeal of it was not perfected and the Board does not have jurisdiction over it. The issue of entitlement to a rating of total disability based on individual unemployability (TDIU) has been raised by the record. The issue of TDIU is part and parcel of a claim for a higher evaluation, and the Veteran has asserted that his service-connected disabilities caused his inability to work. See Rice v. Shinseki, 22 Vet. App. 477 (2009). As such, the Board is remanding the TDIU matter for further development, addressed later in this decision. Increased Rating 1. Entitlement to an evaluation in excess of 20 percent disabling for diabetes mellitus type II is denied. The appellant seeks an increased rating for the Veteran's service-connected diabetes, which was evaluated at 20 percent disabling, effective April 25, 2011. Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1995). A veteran is presumed to be seeking the maximum possible evaluation. AB v. Brown, 6 Vet. App. 35 (1993). Separate ratings can be assigned for separate periods of time based on the facts found a practice known as "staged" ratings. The Veteran's service-connected diabetes mellitus has been rated under 38 C.F.R. § 4.119, Diagnostic Code (DC) 7913. Under DC 7913, a 10 percent rating is warranted for diabetes mellitus which is manageable by restricted diet only. A 20 percent rating is warranted for diabetes requiring insulin and restricted diet; or oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted for diabetes requiring insulin, restricted diet, and regulation of activities. A 60 percent rating requires the use of insulin, a restricted diet, and regulation of activities with 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 total rating of 100 percent is warranted when the disability requires more than one daily injection of insulin, a restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with 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. Compensable complications from diabetes are to be rated separately unless they are part of the criteria used to support a 100 percent evaluation. 38 C.F.R. § 4.119, DC 7913, Note (1). Here, the appellant seeks entitlement to service connection for several conditions argued to be complications of the Veteran's diabetes mellitus type II (DM2), which will be addressed individually later in this decision. In August 2013, the Veteran underwent a VA examination for his diabetes. The examiner confirmed the diagnosis of DM2, observing that medical records showed the condition was managed by restricted diet and prescribed oral hypoglycemic agents and insulin (more than 1 injection per day). The examiner indicated that the condition did not result in a requirement to regulate activities as part of the medical management of the condition. In doing so, the definition of regulation of activities for VA purposes was defined for the examiner. The Veteran was observed to visit his diabetic care provider for episodes of ketoacidosis and hypoglycemic reactions less than 2 times per month. The record did not show that the Veteran had been hospitalized for ketoacidosis or hypoglycemia in the past 12 months, nor that the Veteran had progressive unintentional weight loss. However, the Veteran did show progressive loss of strength attributable to his DM2. See August 2013 (uploaded October 2013) Compensation and Pension (C&P) Examination. Prior to his death, the Veteran argued that he was entitled to a higher evaluation than 20 percent because he had been prescribed insulin since 2011. See, e.g., March 2014 Notice of Disagreement. The appellant echoed this argument during her hearing before the Board. See June 2020 Hearing Transcript. However, the rating criteria for a 20 percent evaluation already contemplates one or more daily injections of insulin, as well as a restricted diet. See 38 C.F.R. § 4.119, DC 7913. In order to receive the next higher evaluation of 40 percent, the rating schedule requires a showing of regulation of activities as part of the medical treatment of the condition. Id. It should be noted that the appellant's representative argued during the hearing before the Board that an increased rating could be warranted by "restrictions to what the Veteran could or could not do as far as exercise is concerned." See June 2020 Hearing Transcript. However, after consideration, the Board finds this does not fall within the VA's regulatory definition or fall in accord with precedential caselaw. "Regulation of activities" has been defined as a situation in which the veteran has been prescribed or advised to avoid strenuous occupational and recreational activities. 61 Fed. Reg. 20,440, 20,466 (May 7, 1996) (emphasis added) (defining "regulation of activities," as used by VA in DC 7913). In this regard, the United States Court of Appeals for Veterans Claims (Court) has explained that the term "regulation of activities" means that a claimant must have a medical need to avoid not only strenuous occupational activity, but also strenuous recreational activity. Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). Medical evidence is required to show that occupational and recreational activities have been restricted. Id. at 364. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1). The Veteran described in his September 2016 VA Form 9 that he personally regulated his activities to be able to manage his diabetes. The Veteran did not explain what restrictions he had placed upon himself, but instead he described generally being less physically capable, due to his diabetes. The record does not show that the Veteran had the necessary medical training or qualifications required to prescribe restrictions for part of his diabetic treatment. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As such, the Veteran's statements in this regard are not competent medical evidence as defined above. The Board thus does not find that the Veteran's self-imposed measures constitute regulation of activities as defined in the Federal Register or by the Court in Camacho. The Veteran's regular treatment records show that throughout the period on appeal, he was prescribed insulin and he received repeated medical guidance for regulating his diet. However, the record is silent for any instance of a treating clinician restricting the Veteran's activities as part of his DM2 management. See generally VA Medical Treatment Records. Additionally, the Board need not consider other diagnostic codes as diabetes mellitus is specifically listed by VA's Rating Schedule. See Copeland v. McDonald, 27 Vet. App. 333, 337 (2015) ("[W]hen a condition is specifically listed in the Schedule, it may not be rated by analogy."). After a review of the evidence of record, the Board finds that an evaluation in excess of 20 percent for DM2 is not warranted. Throughout the period on appeal, the Veteran's DM2 manifested as requiring at least daily insulin shots, prescribed oral hypoglycemic agent, and restricted diet. A higher evaluation of 40 percent is not warranted as the preponderance of evidence does not support that the Veteran was prescribed or advised to avoid strenuous occupational and recreational activities at any time. See Camacho, 21 Vet. App. at 366 (finding that "all criteria must be met to establish entitlement to a 40% rating"). Similarly, the evidence does not tend to show that the Veteran's DM2 condition ever resulted in hospitalization or more than two clinic visits per month. Accordingly, the criteria for a rating in excess of 20 percent are not met, and the claim for an increased rating is denied. 38 C.F.R. § 4.3. Service Connection 2. Entitlement to service connection for peripheral neuropathy, left upper extremity, as secondary to the service-connected disability of diabetes mellitus type II is denied. 3. Entitlement to service connection for peripheral neuropathy, left upper extremity, as secondary to the service-connected disability of diabetes mellitus type II is denied. The appellant seeks entitlement to service connection for bilateral upper extremity peripheral neuropathy, as secondary to his service-connected DM2. The medical history for these arm neuropathy claims overlaps substantially, so the Board will address them together. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must generally be 1) 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) causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In relevant part, 38 U.S.C. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Regulations provide that service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Further, a disability which is aggravated by a service-connected disorder may be service connected to the degree that the aggravation is shown. Allen v. Brown, 7 Vet. App. 439, 449 (1995); 38 C.F.R. § 3.310(b). In order to establish entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; (3) medical evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Board observes that the competent evidence of record does not tend to show that the Veteran was diagnosed with a left upper extremity neuropathy at any time during the period on appeal. The medical evidence is inconsistent as to whether the Veteran's right upper extremity neuropathy was a diabetic neuropathy, or if it stemmed from degeneration and compression of the Veteran's cervical spine. The Board is mindful that the Veteran's bilateral leg neuropathy was attributed to his DM2. However, for the reasons that follow, the Board concludes that the preponderance of evidence weighs against a finding that the Veteran's right upper extremity neuropathy was either proximately caused or aggravated by DM2. In August 2013, the Veteran underwent a VA examination for neuropathy along with examinations for DM2 and other conditions. The examiner wrote that the Veteran had diagnoses of polyneuropathy secondary to diabetes in bilateral lower and bilateral upper extremities from 1999. The Board observes that no such diagnoses are shown in the Veteran's medical records from that time. Moreover, later on the examination form, the examiner wrote that the Veteran did not have an upper extremity diabetic peripheral neuropathy. The left arm did not show any symptoms. The right upper extremity showed moderate constant pain, paresthesias and/or dysesthesias, and numbness. However, physical examination revealed "all normal" upper extremities and the Veteran marked the box "No" regarding if the Veteran has an upper extremity diabetic peripheral neuropathy. In the "Remarks" section of the report, the examiner only remarked concerning peripheral neuropathy of the bilateral lower extremities. Accordingly, the examiner did not provide an etiological opinion or make any further findings regarding the Veteran's upper extremities. See August 2013 (uploaded October 2013) C&P Examination. Shortly after the above examination, also in August 2013, the Veteran sought treatment for neuropathy in his upper and lower extremities. An examining clinician made note that the Veteran had ongoing DM2. The primary care provider assessed neuropathy of the right arm in the form of numbness and started the Veteran on medication. An MRI/CT scan of the neck showed that the Veteran had narrowing of joint space C5-C6 and C6-C7; hypertrophic spurring at C5-C6 and C6-C7; calcific deposits, and neuroforamina narrowing at C5-C6. No findings were made regarding the Veteran's upper left extremity, and the clinician's notes did not specifically attribute the neuropathy to the neck condition, or to DM2, or any other condition in treatment notes. See August 2013 (uploaded November 2013) VA Medical Treatment Record. In November 2013, another VA examiner wrote an addendum opinion to address discrepancies in the above examination. The examiner was asked to address the previous diagnosis of polyneuropathy secondary to diabetes bilateral lower and bilateral upper extremities. The examiner wrote that after review of the Veteran's records, it was her opinion that the Veteran had bilateral lower extremity neuropathy most likely due to diabetes, but he did not have upper extremity neuropathy due to or aggravated by diabetes. The examiner cited to the normal results upon examination in August 2013, as well as to the Veteran's MRI results which showed degeneration in the Veteran's cervical spine, which is often associated with an upper extremity radiculopathy. See November 2013 C&P Examination. In September 2016, the Veteran underwent a VA examination for diabetic sensory-motor peripheral neuropathy. The examiner reviewed the Veteran's claim file and conducted an in-person examination. The Veteran described that his feet felt like needles on the bottom all the time, and he had problems with his toe, and shooting pain up to his calves. The examiner indicated severe constant pain in bilateral lower extremities, with moderate paresthesias and mild numbness. However, the examiner found no evidence of upper right extremity or upper left extremity neuropathy, and both arms were assessed as "normal." See September 2016 examination (uploaded November 2017) VA Medical Treatment Record. In November 2016, the Veteran submitted an internet article to VA from the Mayo clinic which described and defined diabetic neuropathy and its symptoms. Although this evidence does not address the Veteran's case directly, the Board has considered it as probative for background information on diabetic neuropathy. In September 2017, the Veteran asked his treating clinicians for information regarding his recent MRI which showed a cervical spine condition. The Veteran asked if his neuropathic pain and degenerative neck changes could possibly be related to his time on active duty. The treating nurse practitioner wrote an opinion discussing that the Veteran's loss of vertebral height and bulging cervical spine disks appeared to be impinging his nerve fibers and limiting his ability to move his arms at the shoulders, and to establish and maintain a firm grip. The opinion did not address whether the Veteran had previously suffered a neck injury in service. Nonetheless, the nurse practitioner wrote that "there is a possibility" that the cervical changes could be related to service. See September 2017 VA Medical Treatment Record. This note is probative in that it establishes that both the treating nurse practitioner and the Veteran attributed the upper extremity conditions to his cervical spine degeneration. However, the nurse practitioner's opinion did not in any way link the Veteran's upper extremity neuropathy to the his DM2, and it only speculatively attributed the condition to any injury, disease, or incurrence in service. For these reasons, it is given low weight. The Veteran was not service-connected for a cervical spine disability during his lifetime. The record reflects that the appellant has denied that the Veteran suffered a cervical injury at any time. See June 2020 Hearing Transcript. The Veteran's service treatment records do not show any evidence of complaint or treatment for any neck condition. See generally 8/02/2013 STR Medical. This evidence tends to weigh against a finding of an in-service event or injury regarding the cervical spine. With regard to the Veteran's left upper extremity neuropathy, the preponderance of competent and probative evidence does not support that the Veteran had a diagnosed disabling condition for which service connection could be granted. No diagnosis is shown in the record other than the August 2013 VA examiner's finding of a previous diagnosis of bilateral upper extremity diabetic neuropathy, which is not supported by the weight of the competent medical evidence. An overall reading the August 2013 report tends to show no diabetic peripheral neuropathy of the upper extremities, to include as marked in the physical examination section of the report. See Bastien v. Shinseki, 599 F.3d 1301, 1306 (Fed. Cir. 2010) ("The evaluation and weighing of evidence and the drawing of appropriate inferences from it are factual determinations committed to the discretion of the fact finder."); see also Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (explaining that an examination report "must be read as a whole"). Additionally, the subsequent November 2013 VA examiner explained that the previous examiner's finding was erroneous as no diagnosis was shown in the record. On several subsequent examinations, the Veteran's left arm was shown to be asymptomatic. As the first element of service connection a disabling conditionis not established, the claim for left upper extremity neuropathy is denied. Regarding the Veteran's right upper extremity neuropathy, the preponderance of evidence weighs against a finding that the neuropathy was proximately caused or aggravated by service-connected DM2. Although the August 2013 VA examiner made a finding of a previous diagnosis of upper extremity diabetic neuropathy, such is not supported elsewhere in the record by competent and probative evidence, and that finding was disputed by the November 2013 addendum opinion. The Board finds the 2013 opinion to be probative and of much weight as the examiner showed knowledge of relevant facts, to include citing to the normal results upon examination in August 2013 and reviewed and interpreted imaging studies, to include the Veteran's MRI results which showed degeneration in the Veteran's cervical spine and explained that this often associated with an upper extremity radiculopathy. Additionally, the record lacks a competent medical opinion of record that links the Veteran's right arm numbness and pain to his diabetes. Treatment records, as well as the November 2013 addendum opinion, found that the Veteran experienced right arm numbness because of disc degeneration in his neck. The VA examination in September 2016 did not result in any showing of upper extremity neuropathy. Thus, while the Board observes that mild symptoms of right upper extremity neuropathy have been shown during the appeal period, it is not shown to have resulted from diabetes. The secondary service connection criterion of linking the disabling condition to a service-connected condition is not satisfied, and the claim for service connection is denied. 4. Entitlement to service connection for irritable bowel syndrome as secondary to the service-connected disability of posttraumatic stress disorder or medication taken for diabetes mellitus type II is denied. In April 2012, the Veteran submitted a statement seeking service connection for an unspecified "GI condition," gastroesophageal reflux disease (GERD), and irritable bowel syndrome (IBS), including as secondarily due to his service-connected posttraumatic stress disorder (PTSD). See April 2012 VA Form 21-4138 Statement in Support of Claim. Subsequently, the Veteran and the appellant have contended that the Veteran's IBS or gastrointestinal condition may also have been caused or aggravated by his service-connected DM2, to include medications that the Veteran took for his service-connected disabilities. The record shows that service connection was granted for GERD by rating decision in January 2014, with a non-compensable evaluation dated to April 2012. A review of the record does not show that the Veteran was ever diagnosed with IBS, or any gastrointestinal or gastroesophageal condition other than GERD. The Veteran's medical records do not show any diagnosis or history of treatment for IBS. See generally VA Medical Treatment Record. In November 2013, a VA examiner reviewed the Veteran's claim file for esophageal conditions and intestinal conditions. The examiner confirmed the previous diagnosis of GERD, but the examiner indicated that the Veteran had never been diagnosed with an intestinal condition. The examiner considered the onset, course, and symptoms regarding the Veteran's intestinal condition, to include the frequency of his bowel movements and whether he had abdominal pain, bloating, constipation, and/or blood in his stool. No weight loss was noted and there was no functional impact on the Veteran's ability to work. She wrote that the Veteran did not meet the diagnostic criteria for IBS. See November 2013 C&P Examination. Despite the possible avenue of service connection related to medications used for service-connected disabilities, the preponderance of the competent and probative evidence weighs against a finding of current intestinal disability (other than already service-connected GERD). The 2013 opinion is given weigh as the Veteran's relevant medical history, to include noting not functional impairment, and the medical criteria for a diagnoses for IBS were considered. A remand to explore this theory is not warranted here and would only delay final adjudication as the record does not reflect that the competent and probative evidence is in equipoise to support a current disability, to include any functional impairment of earning capacity. Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); see also Degmetich v. Brown, 104 F.3d 1327, 1333 (Fed. Cir. 1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). In absence of a diagnosed disabling condition, the first Shedden requirement for service connection is not satisfied. Although the appellant may sincerely believe that the Veteran had IBS or another gastrointestinal condition for which service connection could be granted, the Board finds the medical record and the VA examiner's opinion to be more probative. Without the requisite training, knowledge, or experience, her statement regarding etiology and not competent and lack weight. As the preponderance of the evidence is against the claim, service connection for IBS is denied. 5. Entitlement to service connection for Bell's palsy as secondary to the service-connected disability of diabetes mellitus type II is granted. The appellant argues that the Veteran's Bell's palsy condition was caused by his service-connected DM2. The competent and probative evidence supports this, as explained next. In June 1999, the Veteran went to the emergency room seeking treatment for the right side of his face drooping. The treating physician diagnosed Bell's palsy, and wrote that it was secondary to the Veteran's diabetes mellitus and smoking. In July 1999, another treating physician confirmed the diagnosis, observing that the emergency room physician had done a thorough workup including a CAT scan and other tests. Both physicians made note of the Veteran's DM2, which had only recently been diagnosed in 1998. See June-July 1999 VA Medical Treatment Records. In August 2013, the Veteran underwent a VA examination for his Bell's palsy. The examiner confirmed the previous diagnosis, and noted that cranial nerve VII (facial) was affected. This resulted in mild right-side mid-face and right-side lower-face numbness, and caused mild difficulty speaking. The examiner wrote that the cause of the condition was "unknown, though conceivably related to diabetes and its complications." See August 2013 (uploaded October 2013) C&P Examination. While the examiner's rationale was thorough, his opinion is insufficient by itself to establish service connection. See Bostain v. West, 11 Vet. App. 124, 127-28, quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993) (stating that a medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish a causal relationship). In November 2013, another VA examiner reviewed the Veteran's claim file to provide an additional medical opinion on Bell's palsy, as the previous examiner's opinion had not been found sufficient for a grant of service connection. The examiner wrote that after review of the Veteran's medical records, the Veteran's condition was less likely as not due to or aggravated by diabetes. By way of rationale, the examiner wrote only that medical literature supports that a viral infection is typically the cause of Bell's palsy, and medical literature did not support a causal relationship to diabetes. However, the examiner did not discuss the absence of evidence a viral infection in the Veteran's record, or in any way discuss the statements made by the diagnosing physician in 1999, or address the temporal association between the Veteran's Bell's palsy and diabetes diagnoses. See November 2013 C&P Examination. The Board therefore finds this opinion holds low probative weight. In September 2016, the Veteran submitted an article from the Journal of Neurology, Neurosurgery and Psychiatry, entitled "Concurrent Bell's Palsy and diabetes mellitus: a diabetic mononeuropathy?" See September 2016 Correspondence. The article does not establish that Bell's palsy is always caused by DM2, but the literature does clearly note that Bell's palsy may be in many cases a diabetic mononeuropathy. This article is probative as it negates the November 2013 VA examiner's rationale that medical literature does not support a causal relationship between DM2 and Bell's palsy. It is given low weight overall as it is does not speak to the specific facts of the Veteran's medical history. The evidence is at least in equipoise that the Veteran's Bell's palsy condition was caused or aggravated by his service-connected diabetes mellitus. The condition onset within a year of the diagnosis of DM2, and the diagnosing physician directly attributed Bell's palsy to DM2 upon the very first examination of the condition. Although the August 2013 VA examiner did not use language consistent with the legal requirements for a grant of service connection, the examiner's opinion and other evidence of record nonetheless tend to show that a link between DM2 and Bell's palsy is plausible. The Board thus finds the diagnosing physician's comments are highly probative, and they show that the Veteran's Bell's palsy condition was at least as likely as not causally linked to his service-connected condition. Therefore, the secondary service connection criteria are met, and the claim for service connection is granted. 38 C.F.R. § 3.102, 3.310(a). 6. Entitlement to service connection for hypertension as secondary to the service-connected disability of diabetes mellitus type II is granted. The appellant contends that the Veteran's hypertension was caused or aggravated by his service connected DM2, or alternatively by his PTSD, or due to his exposure to Agent Orange and other herbicide agents. In August 2013, a VA examiner evaluated the Veteran's hypertension condition in conjunction with evaluating his DM2. The examiner indicated that the Veteran had a previous diagnosis of hypertension from 1998 consistent with VA's diagnostic requirements. On the disability benefits questionnaire (DBQ) form for diabetes, the examiner checked a block to indicate that the Veteran at least as likely as not (at least a 50 percent probability) had permanent aggravation of his hypertension condition due to DM2. On the hypertension DBQ form, the examiner wrote that hypertension often accompanies a diagnosis of diabetes, and "is more likely than not related to the same underlying causes." See August 2013 (uploaded October 2013) C&P Examination. The Board observes the language used on the hypertension DBQ form is insufficient for a grant of secondary service connection; however, the examiner's clear indication on the diabetes DBQ form that hypertension was aggravated by DM2 tends to support a grant of the claim. In November 2013, another VA examiner reviewed the Veteran's record to address deficiencies in the August 2013 opinion. The examiner completed a kidney conditions DBQ, and pointedly did not address DM2 at all. Rather, the examiner repeatedly discussed whether the Veteran's conditions were due to "diabetic nephropathy," which is a kidney complication that can arise from diabetes. The examiner wrote that the Veteran's hypertension was less likely than not due to diabetic nephropathy because the hypertension had arisen around the same time the Veteran's diabetes was diagnosed. See November 2013 C&P Examination. Service connection for nephropathy was not established during the Veteran's lifetime. The Board affords this opinion low probative weight, as it did not directly address whether the Veteran's hypertension was caused or aggravated by his actual service-connected condition. Nonetheless, the Board observes the examiner's opinion did not contradict the previous opinion from August 2013. The evidence is at least in equipoise to support a finding that the Veteran's hypertension was aggravated by his service-connected DM2. The August 2013 VA examiner clearly attributed the etiology of the Veteran's hypertension to his service-connected diabetes. The November 2013 examiner's opinion did not contradict the previous opinion, as it only addressed diabetic nephropathy. Hypertension onset shortly after diabetes, and the competent evidence (including a VA medical opinion) supports a causal linkage. Thus, the secondary service connection criteria are satisfied, and the claim for service connection is granted. 38 C.F.R. § 3.102, 3.310(b). REASONS FOR REMAND Entitlement to TDIU is remanded. The issue of entitlement to a rating of TDIU has been raised by the record. The issue of TDIU is part and parcel of a claim for a higher evaluation, and the Veteran has asserted that his service-connected disabilities caused his inability to work. See Rice v. Shinseki, 22 Vet. App. 477 (2009). Specifically, in a filing with VA, the Veteran stated that his increased symptoms, and having to take insulin for his service-connected DM2 caused him not to be able to secure work anymore. See September 2016 VA Form 9. As such, the Board finds that TDIU has been raised by the record, and must be appropriately developed to ascertain the Veteran's employment history, to include having the appellant complete a VA Form 21-8940 to assist in gather relevant evidence. This matter is REMANDED for the following action: Send the appellant notice regarding TDIU and complete any necessary development, including sending the appellant an application form (VA Form 21-8940) and advising her of the necessity of notifying the AOJ of the Veteran's employment history and his educational background for proper adjudication of this matter. The appellant should be asked to specifically identify by date the period or periods during which the Veteran believed he was unable to work due to service-connected disabilities. Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Hermsdorfer, 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.