Citation Nr: 21039707 Decision Date: 07/01/21 Archive Date: 07/01/21 DOCKET NO. 16-53 329A DATE: July 1, 2021 ORDER Entitlement to service connection for diabetes mellitus is denied. Entitlement to service connection for right upper extremity peripheral neuropathy is denied. Entitlement to service connection for left upper extremity peripheral neuropathy is denied. Entitlement to service connection for right lower extremity peripheral neuropathy is denied. Entitlement to service connection for left lower extremity peripheral neuropathy is denied. REMANDED Entitlement to a rating in excess of 30 percent prior to July 25, 2016 for hypertensive heart disease with cardiomyopathy and supraventricular arrhythmia is remanded. Entitlement to a rating in excess of 60 percent after July 25, 2016 for hypertensive heart disease with cardiomyopathy and supraventricular arrhythmia is remanded FINDINGS OF FACT 1. Diabetes mellitus was not manifested in service, or within one year of separation, and is not attributable to service. 2. Right upper extremity neuropathy was not manifested in service and is not attributable to service and an organic disease of the nervous system did not manifest within one year of separation. 3. Left upper extremity peripheral neuropathy was not manifested in service and is not attributable to service and an organic disease of the nervous system did not manifest within one year of separation. 4. Right lower extremity peripheral neuropathy was not manifested in service and is not attributable to service and an organic disease of the nervous system did not manifest within one year of separation. 5. Left lower extremity peripheral neuropathy was not manifested in service and is not attributable to service and an organic disease of the nervous system did not manifest within one year of separation. 6. Bilateral upper and lower extremity peripheral neuropathy is unrelated (causation or aggravation) to a service-connected disease or injury. CONCLUSIONS OF LAW 1. Diabetes mellitus was not incurred in or aggravated by service and may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1112, 1113, 1116, 1131, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 2. Right upper extremity peripheral neuropathy was not incurred in or aggravated by service and an organic disease of the nervous system may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1112, 1113, 1116, 1131, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 3. Left upper extremity peripheral neuropathy was not incurred in or aggravated by service and an organic disease of the nervous system may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1112, 1113, 1116, 1131, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 4. Right lower extremity peripheral neuropathy was not incurred in or aggravated by service and an organic disease of the nervous system may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1112, 1113, 1116, 1131, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 5. Left lower extremity peripheral neuropathy was not incurred in or aggravated by service and an organic disease of the nervous system may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1112, 1113, 1116, 1131, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 6. Bilateral upper and lower extremity peripheral neuropathy is not proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1977 to December 1994. Service Connection Service connection may be established for disability resulting from personal injury or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. To establish a right to compensation for a present disability, a Veteran must show: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303(a); see also Davidson v. Shinseki, 581 F.3d 1313, 131516 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also 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). In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (providing that a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis if (1) the medical issue is within the competence of a layperson, (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. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). If the evidence is competent, the Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 51112 (1995). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Factual Background The Veteran contends diabetes is due to service and his neuropathy is due to his diabetes. See, e.g., January 2016 VA Form 21-526EZ; July 2014 Notice of Disagreement. Service treatment records note lower extremity problems in service, with metatarsalgia listed in October 1990 and the Veteran spraining his ankle in April 1981. There is no evidence in the service medical records of diabetes or neuropathy. A September 1994 report of medical examination for purposes of retirement noted that the Veteran had a normal clinical evaluation in all areas and had a negative uranalysis for sugar. A report of medical history dated in September 1994 contains the Veteran's report that he was in good health and he was not taking any medication and the Veteran denied neuritis or sugar and albumin in urine. He did report foot trouble, but the Veteran's explanation was that he had painful joints, cramps, and some trouble with his feet when running. When the Veteran established care with VA in January 2004, he complained of tingling feelings in his fingers, legs, arms, and back with onset in the last two to three months. An additional treatment note that same month indicates that the Veteran had intermittent numbness/tingling sensations in the hands or feet that last minutes and seems to abate with rubbing of the areas. This has been present for a couple years but seems to be increasing in frequency. In October 2004, the Veteran was first reported to have symptoms specifically of diabetes and peripheral neuropathy. 1. Diabetes mellitus The Board acknowledges that lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Layno v. Brown, 6 Vet. App. 465, 470 (1994). Further, the Board notes that for certain chronic diseases including diabetes mellitus and organic diseases of the nervous system (which includes neuropathy, which is addressed in the next section), service connection may be granted if the disease becomes manifest to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. The Veteran is not competent to report etiology in the absence of lay observable symptoms. Here, the Veteran first reported in 2004 that his lay observable symptoms started between several months to a couple years prior to when he established care with VA in 2004. While the Veteran's 2004 statement that symptoms existed for a couple of years is vague regarding exact onset of symptoms, such a statement does not indicate that lay observable symptoms existed for eight or more years. Nowhere is there competent evidence of symptoms in December 1995 (one year after service) or before. Therefore, here, diabetes mellitus was not manifested during service or within one year of separation. In addition, he did not have the characteristic manifestations sufficient to identify the disease entity during service or within one year of separation. Rather, during the separation examination the endocrine system was normal, and urinalysis was negative for sugar. In addition, there is no competent evidence of diabetes until many years post service. Currently, there is no acceptable evidence of diabetes during service or within one year of separation. There is no accepted proof that the remote onset of diabetes is otherwise related to service. The disorder is not an undiagnosed illness and not a medically unexplained chronic multisystem illness within the meaning of 38 U.S.C. § 1117. For the reasons expressed above, the preponderance of the evidence is against the claim of entitlement to service connection for diabetes. 2. 5. Upper and lower extremity peripheral neuropathy The Veteran contends neuropathy is due to diabetes. In addition to direct service connection, secondary service connection is warranted for disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Any increase in severity of a non-service connected disease or injury that is proximately due to or the result of a service connected disease or injury, and not due to the natural progress of the nonservice connected disease or injury will be service connected. 38 C.F.R. § 3.310(b). The medical and lay evidence all notes a causal relationship between diabetes and neuropathy. Here, as diabetes mellitus is not service-connected, service connection for neuropathy cannot be granted on any basis pursuant to 38 C.F.R. § 3.310. The Board has also considered other theories. Here, neuropathy was not manifested during service. Rather, at separation, the nervous system and upper and lower extremities were clinically normal on evaluation. The Veteran denied neuritis. The Veteran did have various complaints of the extremities, particularly the lower extremities, in service, but these were due to a variety of other problems (cramps, pain with running, joint pain) and there is no competent evidence that this issues were due to neuropathy, particularly given the unremarkable in-service uranalysis and the normal nervous system. In addition, there is no evidence of neuropathy until multiple years after service. There is no evidence of a chronic disease (organic disease of the nervous system) manifested within one year of service. There is no evidence that neuropathy is otherwise due to service. In addition, the disorder is not an undiagnosed illness or a medically unexplained chronic multisystem illness. For the reasons expressed above, the preponderance of the evidence is against the claims of entitlement to service connection and the claims must be denied. REASONS FOR REMAND According to the representative's Informal Hearing Presentation, the Veteran's heart disability warrants a new examination to assess the current state of the disability. The Veteran's increased rating was based on the date of an echocardiogram performed by VA medical center which revealed left ventricular ejection fraction of 45-50 percent. The Veteran's last examination was in June 2014 and shows the examiner did not conduct MET exercise stress testing or interview-based METs testing to evaluate the disorder, instead relying on a pervious MET exercise stress conducted in October 2013 without providing an explanation for why the testing was not conducted. See 38 C.F.R. § 4.100. The prior METs testing showed results of METs level of 10.1. Treatment records dated after 2014 showed METs Level as low as 4. See, e.g., February 2017 VA treatment record. The representative contends worsening, citing the medical evidence of record, and states this is a further reason an additional examination is needed. Given these arguments and the medical evidence of record, an additional examination is necessary. The matters are REMANDED for the following action: Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of the service-connected hypertensive heart disease with cardiomyopathy and supraventricular arrhythmia. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The examiner should indicate what testing (METs level, left ventricular ejection fraction (LVEF), etc.) was conducted and if any testing necessary for ratings purposes was not conducted, an explanation for why should be provided. H. N. SCHWARTZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Yoffe, 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.