Citation Nr: 21039757 Decision Date: 07/01/21 Archive Date: 07/01/21 DOCKET NO. 17-60 050 DATE: July 1, 2021 ORDER Entitlement to service connection of dermatitis is granted. Entitlement to service connection of ischemic heart disease is denied. Entitlement to service connection of hypertension is denied. Entitlement to an initial rating in excess of 10 percent for lumbar spine strain is denied. Entitlement to an initial increased rating for right lower extremity radiculopathy, associated with lumbar spine strain, presently rated as noncompensable prior to November 13, 2020, and 20 percent disabling thereafter, is denied. Entitlement to an initial increased rating for left lower extremity radiculopathy, associated with lumbar spine strain, presently rated as noncompensable prior to November 13, 2020, and 20 percent disabling thereafter, is denied. REMANDED Entitlement to service connection of diabetes mellitus, type II, is remanded. Entitlement to service connection of right upper extremity neuropathy is remanded. Entitlement to service connection of left upper extremity neuropathy is remanded. Entitlement to service connection of residuals of a stroke is remanded. FINDINGS OF FACT 1. The Veteran's dermatitis had onset during active service with continuity to the present. 2. The Veteran does not have a present diagnosis of ischemic heart disease. 3. The Veteran does not have a present diagnosis of hypertension. 4. For the period on appeal, the Veteran's lumbar strain has resulted in no less than 75 degrees of forward flexion or a combined range of motion of 145 degrees; there is no evidence of muscle spasm or severe guarding, or abnormal spinal contour; there is no evidence of ankylosis. 5. The Veteran's right and left lower extremity radiculopathy, associated with lumbar spine, was not diagnosed until November 13, 2020, at which time it showed no more than some reduced muscle strength and mild paresthesias and/or dysesthesias CONCLUSIONS OF LAW 1. The criteria for service connection of dermatitis are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for service connection for ischemic heart disease are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection of hypertension are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304 4. The criteria for a rating in excess of 10 percent for lumbar spine strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5237. 5. The criteria for a compensable disability rating prior to November 13, 2020, and in excess of 20 percent thereafter for right lower extremity radiculopathy associated with lumbar strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.71a, DC 5237, Note (1), 4.124a, DC 8620. 6. The criteria for a compensable disability rating prior to November 13, 2020, and in excess of 20 percent thereafter for left lower extremity radiculopathy associated with lumbar strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.71a, DC 5237, Note (1), 4.124a, DC 8620. REASONS AND BASES FO FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1966 to June 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from June 2015 and March 2017 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). This appeal previously came before the Board in May 2019, at which time the Board remanded the issues remaining on appeal in this matter. Also remanded at that time were claims of service connection for bilateral lower extremity neuropathy (later diagnosed as radiculopathy) and entitlement to total disability based on individual unemployability (TDIU). Following the development that was ordered by the Board, as well as any additional development that was deemed warranted by the RO, those claims were granted in full and are no longer part of this appeal. While the claims of service connection for right and left lower extremity radiculopathy/neuropathy are no longer before the Board, the rating criteria for the lumbar spine disability instructs the rating body to include consideration of ratings for any associated neurological symptoms separately under the applicable diagnostic criteria. 38 C.F.R. § 4.71a, DC 5237, Note (1). As such, the Board has included consideration of the ratings assigned for those disabilities, as they are service-connected as a neurological complication of the lumbar strain. The Board observes that in May 2021, the Veteran's representative submitted a letter unilaterally withdrawing from representing the Veteran in this matter (sent directly to the Board and copied to the Veteran). Although the Veteran has not appealed the representative's withdrawal, the Board finds that adequate evidence has not been shown to warrant a withdrawal at this time, and the motion is denied. The attorney remains the representative of record. 38 C.F.R. § 20.6(a)(2). The Board recognizes that in its prior decision/remand, it combined the claims of service connection of ischemic heart disease and ischemic stroke into a single claim of service connection of ischemic heart disease to include residuals of a stroke. Based on a review of the evidence at this time, the Board finds that the two claims are better addressed separately, and have thus characterized them as such in this decision. Service Connection The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. 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). Generally, establishing service connection requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). In addition, certain chronic diseases, including tuberculosis, may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Further, if a veteran was exposed to an herbicide agent during active military, naval, or air service in Vietnam, then certain diseases, such as chronic lymphocytic leukemia, shall be service connected even though there is no record of such disease during service. For the purposes of this section, the term "herbicide agent" means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the Vietnam era. 38 U.S.C. § 1116 (2012); 38 C.F.R. §§ 3.307(a)(6), 3.309(e), 3.313 (2017). 1. Entitlement to service connection of dermatitis The Veteran seeks service connection of dermatitis. The Board finds that the claim should be granted. The Veteran's service treatment records indicate that he was treated for dermatitis during active service beginning in 1967, with multiple skin complaints as late as 1969. For his part, the Veteran asserts that his dermatitis started during active service, with continuity to the present. The Veteran was afforded a VA examination in May 2015. The examiner diagnosed dermatitis and gave the date of initial diagnosis as March 1969, which corresponds with his service treatment records. The condition was described as dry, itching, flaky skin rash on the legs, arms, and elbow. A steroid cream had been used in the past, but no current treatment was prescribed. Despite giving a date of initial onset in 1969, the examiner concluded that the condition was less likely than not related to active service as there was no evidence in the record documenting continuity of medical care from the initial date of onset. For his part, the Veteran asserts that his condition had onset during active service and has continued to the present in various states over the years. While the Board recognizes that the examiner opined against service connection, it finds the opinion of limited probative value in this matter. Specifically, the opinion relies exclusively on a lack of medical records proving continuity of symptoms from the time of service. However, the opinion does not consider or discuss the Veteran's own assertions of continuity since service, and a lack of medical evidence alone is insufficient to negate those assertions. Ultimately, the Board will afford the Veteran the benefit of the doubt and find that his condition first manifested in service (as confirmed by the 2015 examiner) and had continuity since that time. In this regard, the Board finds that the Veteran's lay statements regarding continuity are both competent and credible. Particularly given the examiner's conclusion that the disability first had onset in 1969. See Caluza v. Brown, 7 Vet. App. 498 (1995); Layno v. Brown, 6 Vet. App. 465, 471 (1994); Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). As the condition began in service and has continued since service, the Board finds that the criteria for service connection are met, and the claim is granted. 2. Entitlement to service connection of ischemic heart disease 3. Entitlement to service connection of hypertension The Veteran seeks service connection of ischemic heart disease hypertension. The Board finds that the claims should be denied. As an initial matter, the Board recognizes that the Veteran served in the Republic of Vietnam, and therefore has conceded exposure to herbicides. Further, ischemic heart disease is a disability for which presumptive service connection is granted secondary to herbicide exposure. Therefore, the only question before the Board is whether or not the Veteran has a present diagnosis of "ischemic heart disease." The Board finds that this is not the case With regard to the hypertension claim, that disability is not a "presumptive" disability secondary to herbicide exposure, although that does not preclude service connection on a direct basis. Nonetheless, the Board finds that the claim fails the primary criterion of service connection, namely, a present diagnosis of hypertension. The Veteran was afforded a VA examination in May 2015. The examiner reviewed all available private and VA treatment records, and conducted an examination of the Veteran. The examiner then declined to diagnose ischemic heart disease, although a stroke in 2012 was noted, as was hypertension. An addendum to that examination also declined to give a diagnosis of heart disease. Notably, the examiner also retracted the diagnosis of hypertension, noting that all complaints and signs of hypertension were per the Veteran's report only- there is not enough medical evidence in the claims file to support any diagnosis of hypertension on the day of the examination. A review of private treatment records submitted with the Veteran's claim include indication of "brief hypertension" throughout his hospitalization for a stroke in 2012, but that the condition improved throughout his hospitalization, and he was off all anti-hypertensive medications at the time of discharge. Even presuming that the Veteran's blood pressure reached hypertensive levels while hospitalized, that incident occurred prior to the Veteran's claim, and there is no indication during the appeal period that he has experienced a similar episode or ongoing elevated blood pressure. No other actual diagnosis of hypertension is given in the record, and there is no evidence that the Veteran had active hypertension during his appeal period. Following the Board's prior remand, the Veteran was requested to identify any outstanding medical evidence which might show either ischemic heart disease or hypertension during the appeal period, but neither the Veteran nor his representative responded to that request. Based on the available evidence, the Board must conclude that the evidence does not support a present diagnosis of either hypertension or ischemic heart disease. As such, the Board will deny both of these claims as both fail the primary criterion of service connection. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. The Board does acknowledge that the Veteran has also claimed service connection of residuals of "ischemic stroke." To the extent that the record does reflect a stroke in 2012, but is separate from a diagnosis of ischemic heart disease or hypertension, that issue is addressed in further detail in the below remand. Increased Rating Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran's entire history is reviewed when making disability evaluations. See generally, Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where, as in the case of the Veteran's lumbar spine disability, the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of staged ratings are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Further, "[w]here there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned." 38 C.F.R. § 4.7. 4. Entitlement to an initial rating in excess of 10 percent for lumbar spine strain 5. Entitlement to an initial increased rating for right lower extremity radiculopathy, associated with lumbar spine strain, presently rated as noncompensable prior to November 13, 2020, and 20 percent disabling thereafter 6. Entitlement to an initial increased rating for left lower extremity radiculopathy, associated with lumbar spine strain, presently rated as noncompensable prior to November 13, 2020, and 20 percent disabling thereafter The Veteran appeals the 10 percent rating for lumbar strain which has been assigned from the initial date of service connection. The Board finds that the claim should be denied. The Veteran's lumbar strain is rated under Diagnostic Code (DC) 5237, which applies the General Rating Formula for diseases and Injuries of the Spine. Under the applicable rating criteria, a 10 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, DC 5237. A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine; a 100 percent rating is assigned for unfavorable ankylosis of the entire spine (thoracolumbar and cervical). Id. A disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40 With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of "the normal working movements of the body," such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40 ); see also DeLuca v. Brown, 8 Vet. App. 202, 206-207 (1995). A rating for a spine disability is also available based on the presence of intervertebral disc disease (IVDS) under DC 5243. This rating is an alternative method to rating under the General Formula and only for application where it would give rise to a higher rating. In the present matter, IVDS is not shown in the record, and therefore such consideration is not appropriate. While the claims of service connection for right and left lower extremity radiculopathy/neuropathy are no longer before the Board, as discussed above, the rating criteria for the lumbar spine disability instructs the rating body to include consideration of ratings for any associated neurological symptoms separately under the applicable diagnostic criteria. 38 C.F.R. § 4.71a, DC 5237, Note (1). Here, the Board observes that service connection of right and left lower extremity radiculopathy was granted effective November 13, 2020, with 20 percent ratings assigned for each extremity. As such, the Board must also consider ratings for the lower extremity radiculopathy as part of the spine appeal. The Veteran's right and left lower extremity radiculopathy is rated under DC 8620, which compensates for neuritis affecting the sciatic nerve. Under the applicable criteria, a 10 percent rating is assigned for mild incomplete paralysis of the sciatic nerve. A 20 percent rating is assigned for moderate incomplete paralysis of the sciatic nerve. A 40 percent rating is assigned for moderately severe incomplete paralysis of the sciatic nerve. Severe incomplete paralysis of the sciatic nerve, which is described explicitly as "with marked muscular atrophy," is assigned a 60 percent rating. Finally, complete paralysis of the sciatic nerve, explicitly described as "the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost," is assigned an 80 percent rating. 38 C.F.R. § 4.124a, DC 8620. In the present matter, terms such as "mild," "moderate," and "moderately severe" are not generally defined by the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Turning to the evidence of record, the Veteran was afforded an examination in May 2015, in connection with his service connection claim. Forward flexion was to 80 degrees with evidence of painful motion at 80 degrees. Combined range of motion was to 230 degrees with pain limiting combined range of motion at 230 degrees. No change was found based on repetitive use testing. No additional functional loss or factors limiting movement was found. No guarding or muscle spasm was observed. Muscle strength was normal on all planes and he had no evidence of muscle atrophy. Reflexes were normal. A negative straight leg test was found on the right, but positive on the left. However, radiculopathy was not found at that time and the examiner noted no symptoms of radiculopathy. No IVDS was found. He did not require the use of an assistive device. No other pertinent physical findings were reported. The examiner stated that it was not possible to determine, without resort to speculation, if limitation of motion is present due to pain during flare-ups or when the spine was used repeatedly over time, as actual observation during such a period would be necessary. The Veteran was afforded a new VA examination on November 13, 2020. At that time the Veteran reported worsening symptoms interfering with his ability to perform activities of daily living. Specifically, he stated that he could not stand for long periods of time and unable to pick up anything off the floor. He used a back brace. Forward flexion was to 85 degrees with evidence of pain at 80 degrees. Combined range of motion was 205 degrees with pain limiting total motion at 175 degrees. Repetitive use over time limited forward flexion to 75 degrees with combined range of motion limited to 145 degrees. The Veteran denied flare-ups. Muscle strength showed active movement against some resistance. Reflexes were normal. Light touch testing was normal. Straight leg raising test was negative bilaterally, although radiculopathy was diagnosed, resulting in mild paresthesias and/or dysesthesias bilaterally, but no evidence of constant pain, intermittent pain or numbness. No other signs of radiculopathy were found. The examiner opined that the radiculopathy attributed to the Veteran's lumbar strain was mild in nature bilaterally. There was no evidence of ankylosis or any other neurological abnormalities. He did not have IVDS. He occasionally used a cane to ambulate. Functionally, the examiner noted that his spine condition would limit his ability to stand for a long period of time and prevent him bending to pick objects up from the floor, requiring an aid for such actions. Also conducted at the same time was a peripheral nerve examination. The Veteran primarily reported symptoms in his upper extremities, particularly numbness in his fingers. The examiner found evidence of mild paresthesias and/or dysesthesias in the lower extremities, but no evidence of constant pain, intermittent pain, or numbness. Strength was 4/5 indicating active movement against some resistance on all movements in the lower extremities. He did not have any evidence of muscle atrophy. Deep tendon reflexes were all normal. Sensation testing was all normal. There were no trophic changes. Gait was normal. The examiner opined that the Veteran showed mild incomplete paralysis of the sciatic nerve. His radiculopathy did not contribute to his use of an assistive device to ambulate. The examiner stated that functionally, his radiculopathy contributed to his inability to stand for long periods of time or pick objects up from the floor. The Board has reviewed the available evidence but finds nothing else that would give insight to the severity of the Veteran's lumbar spine disability with associated radiculopathy. Particularly, the Board notes that the Veteran was afforded the opportunity to identify any outstanding private treatment records following the most recent Board remand, but did not respond, nor did he submit any additional medical or lay evidence on his own behalf. Based on the evidence of record, the Board finds that a rating in excess of 10 percent for the lumbar spine is not warranted at any period on appeal. In this regard, the most significant limitation of forward flexion was to 75 degrees (to include consideration of repetitive movement and painful motion), with a combined limitation of range of motion to 145 degrees. This limitation of motion is only accommodated by a 10 percent rating under the diagnostic criteria. Neither is there any evidence of other symptoms affecting the spine such as guarding, spasms, abnormal gait, abnormal spinal contour, or ankylosis (either diagnosed or functional). As such, the Board must conclude that based on the evidence of record, a rating in excess of 10 percent for the spine is not supported at any period on appeal. Regarding the Veteran's radiculopathy, the Board finds that prior to November 13, 2020, the criteria for a compensable rating are not met. Although the Veteran certainly asserts radicular symptoms during that period, as demonstrated by his claim in general, there is no medical evidence to show that he met the diagnostic criteria for a diagnosis of radiculopathy prior to that date. Indeed, his 2015 examination found no such diagnosis or any symptoms which could be attributed to radiculopathy of the lower extremities that was associated with the low back disability. Reflexes, muscle strength and sensory testing were all normal and no radicular symptoms such as constant pain, intermittent pain, dysesthesias and/or paresthesias, or numbness were asserted or documented. As such, the Board concludes that a rating for right or left lower extremity radiculopathy is not supported prior to November 13, 2020. From November 13, 2020, the Board finds that a rating in excess of 20 percent for each lower extremity is also not supported. In this regard, the Veteran is rated based on "moderate" symptoms. However, the Board does not find that the symptoms are "moderately severe" in nature such that a higher rating is warranted. Indeed, both the spine examination and the neurological examination conducted that day found generally mild symptoms. At most, he has demonstrated some mild dysesthesias or paresthesias, but there is no evidence of constant pain or even intermittent pain. He has asserted numbness in his fingers but not his lower extremities. He has some weakened muscle strength, but is still able to show movement against resistance. His reflexes are all normal. His sensation testing was completely normal. He has no evidence of trophic changes. There is certainly no evidence of muscle atrophy or more serious symptoms such as foot dangle or loss of use of the legs. Based on this, the Board concludes that "moderately severe" symptoms are not shown, and a rating in excess of 20 percent for each lower extremity radiculopathy, associated with lumbar strain, is not supported In sum, the Board finds that increased ratings for lumbar strain and associated right and left lower extremity radiculopathy are not supported, and the claim for an increased rating is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection of diabetes mellitus, type II, is remanded The Veteran was afforded a VA examination in May 2015, which initially diagnosed diabetes mellitus, type II, but then retracted that diagnosis in exchange for a diagnosis of impaired fasting glucose. Nonetheless, the evidence does indicate issues with his glucose in January 2015 and possibly in January 2012. The Veteran also reported that he was required to follow a diabetic diet to control his blood sugar. Although the Board previously remanded this appeal for any outstanding private treatment records, the Veteran did not identify any such records during the remand period. Nonetheless, the Board finds the May 2015 examination to be inadequate on its own. First, it is unclear whether or not the Veteran has a diagnosis of diabetes mellitus based on the contradictory reports. Further, the Board notes that even if the Veteran does not have a diagnosis of diabetes mellitus, he does potentially have a diagnosis of impaired fasting glucose. Although presumptive service connection is not available for impaired fasting glucose, the Board must still consider whether that diagnosis is related to his conceded in-service herbicide exposure. As such, the Board will remand this appeal so that a new examination may be conducted which clarifies the Veteran's diagnosis, and provides an etiology opinion if necessary. 2. Entitlement to service connection of right upper extremity neuropathy is remanded. 3. Entitlement to service connection of left upper extremity neuropathy is remanded. The Veteran was afforded a VA examination in connection with his neuropathy claims in November 2020, which included a diagnosis of bilateral upper and lower extremity radiculopathy. The Veteran's right and left lower extremity radiculopathy was subsequently granted, as a VA spine examination found his radiculopathy to be a residual of his service-connected lumbar spine strain. However, the examination did not include an etiology opinion regarding the cause of the Veteran's upper extremity neuropathy (either secondary to his spine disability or directly related to any herbicide exposure in service). The Board also notes that because neurological symptoms may be a sign of the diabetic process, these claims must also be remanded as intertwined with the diabetes claim also remanded herein. 4. Entitlement to service connection of residuals of a stroke, is remanded. The Veteran seeks service connection of ischemic heart disease and residuals of ischemic stroke, as well as service connection of hypertension. The Veteran was afforded a VA examination in connection with these claims in May 2015. Although the Veteran has not identified any subsequent private treatment records, the Board nonetheless finds the May 2015 examination inadequate as it does not provide an opinion regarding the cause of the Veteran's stroke. Specifically, to date, the claim has been denied because stroke is not a presumptive disability secondary to herbicide exposure, and there is no other in-service incident, illness or injury to which the stroke may be etiologically linked. However, that stroke is not a presumptive disability under statutory guidelines does not preclude service connection on a direct basis if a nexus can be established between the stroke and herbicide exposure. The fact that the Veteran claims his stroke is "ischemic" in nature implies that he alleges a connection to herbicide exposure; to date an opinion has not been rendered. As such, the Board will request a medical opinion with regard to this claim. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination with an appropriate clinician regarding his claimed diabetes mellitus, type II. The claims file should be made available and reviewed. The examiner is requested to review the available evidence and conduct any necessary testing necessary to determine whether or not the Veteran has a present diagnosis of diabetes mellitus, or any other blood-sugar or insulin-related disability. If diabetes mellitus is diagnosed, the examiner need not provide any further etiology opinion. For any other diagnosed disability, the examiner is requested to state whether it is at least as likely as not related to his in-service herbicide exposure. A rationale should accompany any opinion rendered. 2. Obtain an addendum opinion from an appropriate clinician regarding the claimed upper extremity radiculopathy. The claims file should be made available and reviewed. The examiner is requested to review the available evidence and examination reports and provide answers to the following questions: a. Is it at least as likely as not that the Veteran's upper extremity radiculopathy is related to any incident of active service, to include herbicide exposure? b. Is it at least as likely as not that the Veteran's upper extremity radiculopathy is (a) caused or (b) aggravated by the Veteran's service-connected lumbar spine disability? c. If the Veteran is found to have diabetes mellitus, is it at least as likely as not that any of the Veteran's upper extremity neurological symptoms are (a) caused or (b) aggravated by the Veteran's diabetes? 3. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's 2012 stroke and residuals thereof. The claims file should be made available and reviewed. The examiner is requested to review the evidence of record and state whether it is at least as likely as not that the Veteran's 2012 stroke with residuals was related to any incident of active service, specifically to his conceded herbicide exposure. B.T. KNOPE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Pryce, Counsel