Citation Nr: 21039987 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 13-32 770 DATE: July 2, 2021 ORDER An initial compensable disability rating for hypertension is denied. An initial disability rating greater than 30 percent for left ventricular hypertrophy and cardiomegaly (heart disability) is denied. An initial disability rating of 60 percent for diabetic nephropathy is granted, effective May 12, 2017. Service connection for a low back disability is denied. REMANDED The following issues are remanded for further development: (1) entitlement to an initial disability rating greater than 20 percent for peripheral neuropathy of the right upper extremity; (2) entitlement to an initial disability rating greater than 20 percent for peripheral neuropathy of the left upper extremity; (3) entitlement to an initial disability rating greater than 10 percent from April 12, 2010 to January 7, 2018, greater than 40 percent from January 8, 2018 to August 27, 2019, and greater than 20 percent from August 28, 2019 onward, for peripheral neuropathy of the right lower extremity; (4) entitlement to an initial disability rating greater than 10 percent from April 12, 2010 to January 7, 2018, greater than 40 percent from January 8, 2018 to August 27, 2019, and greater than 20 percent from August 28, 2019 onward, for peripheral neuropathy of the left lower extremity; and (5) entitlement to a total disability rating based upon individual unemployability (TDIU). FINDINGS OF FACT 1. The evidence of record demonstrates that the Veteran does not have diastolic pressure predominantly 100 or more, or systolic pressure predominantly 160 or more. Additionally, while the Veteran does require continuous medication for control of his hypertension, he does not have a history of diastolic pressure predominantly 100 or more. 2. The evidence of record indicates that the Veteran did not experience more than one episode of congestive heart failure or display left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Additionally, the evidence of record does not demonstrate that workloads of greater than 3 but less than 5 METs resulted in symptoms of dyspnea (difficult or labored breathing), fatigue, angina (chest pain), dizziness, or syncope (temporary loss of consciousness) during the claim period. 3. Prior to May 12, 2017, the Veteran's diabetic nephropathy did not cause constant or recurring albumin with hyaline and granular casts or red blood cells, transient or slight edema, or a definite decrease in kidney function. For the entire claim period, the Veteran's diabetic nephropathy did not result in persistent edema and albuminuria with BUN 40 to 80mg%; creatinine 4 to 8mg%; or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. 4. While the Veteran has a current low back disability, the evidence of record does not demonstrate that this current disability was incurred in, caused by, or is otherwise related to service. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for hypertension are not met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.100, 4.104, Diagnostic Code 7101; McCarroll v. McDonald, 28 Vet. App. 267 (2016). 2. The criteria for an initial disability rating greater than 30 percent for a heart disability are not met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.100, 4.104, Diagnostic Code 7020. 3. The criteria for an initial disability rating of 60 percent, but no higher, for diabetic nephropathy are met, effective May 12, 2017. Prior to that date, the criteria for a compensable rating are not met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 3.400, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.115, 4.115a, 4.115b, Diagnostic Code 7541. 4. The criteria for service connection for a low back disability are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1961 to June 1963 and from August 1963 to June 1966, including service in the Republic of Vietnam. These matters come before the Board of Veterans' Appeals (Board) on appeal from March 2011, November 2011, and December 2013 rating decisions of Department of Veterans Affairs (VA) Regional Offices (ROs). Jurisdiction of the Veteran's claims file currently resides with the Atlanta, Georgia RO. In May 2017, the Veteran and his spouse testified at a Board hearing before a Veterans Law Judge (VLJ). A transcript of the hearing is of record. In October 2017, the Board dismissed the issues of entitlement to increased ratings for diabetes mellitus and erectile dysfunction. The Board also remanded the issues of entitlement to service connection for a low back disability and an acquired psychiatric disorder; entitlement to increased ratings for bilateral upper and lower extremity peripheral neuropathies, hypertension, a heart disability, and diabetic nephropathy; and entitlement to a TDIU. Then, in April 2019, the Board denied entitlement to an effective date prior to January 21, 2011 for the award of service connection for a heart disability. The Board then remanded the issues of entitlement to service connection for a low back disability and an acquired psychiatric disorder; entitlement to increased ratings for bilateral upper and lower extremity peripheral neuropathies, hypertension, a heart disability, and diabetic nephropathy; and entitlement to a TDIU. Following the April 2019 Board decision and remand, a VA RO issued a rating decision in October 2020. In this rating decision, the RO: (1) increased the Veteran's diabetic nephropathy rating from noncompensable to 60 percent, effective August 28, 2019; (2) decreased the Veteran's right and left lower extremity peripheral neuropathy ratings from 40 percent to 20 percent, effective August 28, 2019; and (3) granted service connection for persistent depressive disorder with anxious distress. With respect to the award of service connection, the Board finds that this grant constituted a full award of the benefit sought on appeal. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997) (holding that where an appealed claim for service connection is granted during the pendency of the appeal, a second notice of disagreement must thereafter be timely filed to initiate appellate review of the claim concerning "downstream" issues, such as the compensation level assigned for the disability and the effective date). Accordingly, the issue of entitlement to service connection for an acquired psychiatric disorder is no longer in appellate status. Comparatively, regarding the diabetic nephropathy increased rating issue, increase announced in the October 2020 rating decision did not represent a total grant of the benefit sought on appeal. Accordingly, this issue remains in appellate status. AB v. Brown, 6 Vet. App. 35 (1993). Thereafter, in December 2020, the Veteran was informed via letter that the VLJ who conducted the May 2017 hearing was no longer employed by the Board. The Veteran was offered the opportunity to have another hearing. If he did not reply in 30 days, the letter indicated that the Board would assume he did not want an additional hearing. The Veteran did not reply to the December 2020 letter. The Board sent the Veteran an additional hearing clarification letter in April 2021. Again, the letter informed the Veteran that if he did not reply within 30 days, the Board would assume that he did not want another hearing. The Veteran did not respond to the April 2021 letter. Accordingly, the Board will proceed to address the Veteran's appeal without first scheduling an additional hearing. Increased Ratings 1. Hypertension As indicated above in the Conclusions of Law section, the Board finds that the Veteran is not entitled to an initial compensable rating for hypertension. Accordingly, the Board denies the Veteran's claim. In support of this determination, the Board first notes that the Veteran's service-connected hypertension has been assigned an initial noncompensable rating pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7101. Under Diagnostic Code 7101, a compensable rating is assignable when either of 3 criteria are satisfied: (1) when diastolic pressure is predominantly 100 or more; (2) systolic pressure is predominantly 160 or more; or (3) an individual has a history of diastolic pressure of predominantly 100 or more and requires continuous medication for control. 38 C.F.R. § 4.104. In McCarroll v. McDonald, the Court of Appeals for Veterans Claims (Court) interpreted Diagnostic Code 7101 and clarified its application in the increased rating context. 28 Vet. App. 267, 272 (2016). The Court first stated that the criteria for compensable ratings under Diagnostic Code 7101 "contemplate two factual alternatives[:]" (1) a veteran whose blood pressure is currently controlled by medication, but who has a history of diastolic pressure predominantly 100 or more, is entitled to the minimum compensable rating of 10 percent; or (2) if the blood pressure is not controlled by medication, the actual blood pressure level determines the disability rating from 20 to 60 percent. Id. The Court then specified that a finding of "predominantly 100 or more" may not be substantiated by merely one diastolic pressure reading of 100. Id. at 274. Applying these controlling principles to the instant case, the Board first notes that the Veteran's hypertension is controlled by continuous medication. Indeed, treatment with continuous medication was noted by VA examiners in May 2016 and August 2019. Consistent with these statements by VA examiners, private provider Dr. Miller remarked in April 2013 that the Veteran's hypertension was controlled by his then-current medication regimen. Thus, as the Veteran's hypertension is controlled by continuous medication, the only avenue for the Veteran to receive a compensable, 10 percent rating is if the evidence of record demonstrates a history of diastolic pressure of predominantly 100 or more. See McCarroll, 28 Vet. App. at 272. In reviewing the evidence of record, the Board finds only one relevant blood pressure reading where diastolic pressure was 100from a February 2012 visit to the DeKalb Medical Physicians Group. Indeed, during VA examinations in May 2016 and August 2019, the Veteran's blood pressure was measured as 116/78, 115/68, 115/78, 120/80, and 120/78. Separate from these VA examination reports associated with the claims file, the following blood pressure readings were recorded in visits to the DeKalb Medical Physicians Group from September 2010 through May 2013: 122/78, 120/76, 110/70, 130/82, 140/96, 112/70, 132/78, 124/81, 122/78, and 154/96. In additional records from the DeKalb Medical Physicians Group dated through October 2016, which VA received in May 2017, the following blood pressure readings were recorded: 149/93, 113/72, 127/77, 149/93, 128/86, 151/94, 144/90, 130/88, 111/72, 142/91, and 117/77. Similar to the appellant in McCarroll, in the instant case, the evidence of record includes one blood pressure reading where the Veteran's diastolic pressure was measured as 100 or more. However, the remainder of the blood pressure readings did not register diastolic pressure at least 100. Accordingly, the Board may not conclude that the Veteran has a history of diastolic pressure of predominantly 100 or more. As the Veteran does not have a history of diastolic pressure of predominantly 100 or moreand his hypertension is controlled through the use of continuous medicationthe Board finds that entitlement to an initial compensable rating is not warranted. See 38 C.F.R. § 4.104, Diagnostic Code 7101. Thus, the Veteran's claim is denied. 2. Heart Disability Similar to the above issue of hypertension, the Board finds that the Veteran is not entitled to a disability rating greater than 30 percent for his service-connected heart disability. Accordingly, the Board denies the Veteran's claim. In support of this determination, the Board first notes that the Veteran's current 30 percent rating was assigned pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7020. Under Diagnostic Code 7020, a 30 percent rating is assigned when a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray. Comparatively, a 60 percent rating is assigned when a claimant has more than one episode of acute congestive heart failure in the past year, or; a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Lastly, a 100 percent rating is assignable when there is evidence of chronic congestive heart failure, or; a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; there is left ventricular dysfunction with an ejection fraction of less than 30 percent. In applying Diagnostic Code 7020, METs testing is required unless: (1) there is a medical contraindication; (2) the left ventricular ejection fraction has been measured and is 50% or less; (3) chronic congestive heart failure is present or there has been more than one episode of congestive heart failure within the past year; or (4) a 100 percent rating may be assigned on another basis. See 38 C.F.R. § 4.100(b). Turning to the evidence of record, the Board first acknowledges the May 2017 Board hearing testimony. The Veteran's representative first explained that, since May 2014, the Veteran experienced symptoms of an irregular heartbeat, chest pain, dyspnea, and fatigue. See Hearing Tr. at 7. The Veteran then testified that he fatigued easily, even when performing normal activities like walking up stairs or walking short distances like 30 to 40 feet. Id. at 10. The Veteran then indicated that he experienced symptoms of dizziness, particularly when he is in a seated position and stands up too quickly. Id. at 12-13. Consistent with his May 2017 Board hearing testimony, the Board notes that a discharge summary from DeKalb Medical Center associated with the claims file indicated that, in November 2011, the Veteran was hospitalized after experiencing dizziness and falling. An echocardiogram was performed and indicated a left ventricular ejection fraction of 60 percent. Lastly, while the Veteran was given a discharge diagnosis of vertigo, the medical professional who drafted the summary specified that the Veteran's vertigo was of unclear etiology. Separate from his May 2017 testimony and the November 2011 discharge summary, the Board notes that 3 VA examination reports are currently associated with the Veteran's claims file which address the nature and severity of his service-connected heart disability. Firstly, in conjunction with a January 2011 VA examination for multiple disabilities, an echocardiogram was performed. This echocardiogram indicated that the Veteran had a left ventricular ejection fraction of 60 to 65 percent. METs testing was not performed. Thereafter, in May 2016, the Veteran was provided a VA heart conditions examination during which he was diagnosed with left ventricular hypertrophy associated with diabetes mellitus. The Veteran then reported an equilibrium imbalance while walking. The Veteran then discussed, in his own words, his physical capabilities and limitations. He indicated that he was able to: walk the cul-de-sac in his neighborhood; walk up and down the 13 stairs in his home without an assistive device or stopping to catch his breath; and walk 4 to 5 minutes on a treadmill. The examiner then indicated that, after reviewing the claims file and conducting a physical examination, the Veteran did not ever experience congestive heart failure. The examiner then noted that an echocardiogram had been performed in conjunction with the examination. The echocardiogram noted a left ventricular ejection fraction of 55 to 60 percent. Lastly, the examiner stated that an interview-based METs test had been performed with results of greater than 5 to 7 METs. The examiner explained that this METs level had been found to be consistent with activities such as walking one flight of stairs, golfing without a cart, mowing a lawn with a push mower, and performing heavy yard work. Lastly, during an August 2019 VA heart conditions examination, a VA examiner determined that the Veteran did not have congestive heart failure. The examiner conducted an interview-based METs test but indicated that the Veteran denied experiencing symptoms attributable to a cardiac condition with any level of physical activity. In light of the above evidence of record, the Board finds that entitlement to a disability rating greater than 30 percent is not warranted. Specifically, congestive heart failure was not noted in any VA examination report, VA treatment record, or private treatment record associated with the Veteran's claims file. Additionally, the Veteran only displayed a left ventricular ejection fraction of 55 to 60 percent during the claim period at the time of the May 2016 VA examination. Lastly, the most restrictive METs testing result associated with the claims file was greater than 5 but not greater than 7 METs. As the Veteran did not display at least 1 episode of acute congestive heart failure; left ventricular dysfunction with an ejection fraction of 30 to 50 percent; or dyspnea, fatigue, angina, dizziness, or syncope, with a workload of greater than 3 METs but not greater than 5 METs during the claim periodand such evidence is necessary to assign the next higher rating of 60 percent under Diagnostic Code 7020entitlement to a disability rating greater than 30 percent for a service-connected heart disability must be denied. See 38 C.F.R. § 4.104. 3. Diabetic Nephropathy Lastly, as stated above in the Conclusions of Law section, the Board finds that the Veteran is entitled to a disability rating of 60 percent for his diabetic nephropathy, effective May 12, 2017. Prior to that date, a compensable rating is not warranted. Accordingly, to this extent, the Board grants the Veteran's claim. In support of this determination, the Board first notes that the Veteran is currently in receipt of a noncompensable rating from April 12, 2010 to August 28, 2019, and 60 percent thereafter, for his diabetic nephropathy. These ratings were assigned pursuant to 38 C.F.R. § 4.115b, Diagnostic Code 7541. Diagnostic Code 7541 directs VA to evaluate "renal involvement in diabetes mellitus" as renal dysfunction. The criteria for evaluating renal dysfunction are provided for in 38 C.F.R. § 4.115a. Under 38 C.F.R. § 4.115a, a noncompensable rating is assigned for renal dysfunction with albumin and casts with a history of acute nephritis; or, hypertension rated as non-compensable under Diagnostic Code 7101. A 30 percent rating is assigned for renal dysfunction with albumin constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under Diagnostic Code 7101. A 60 percent rating is assigned for constant albuminuria with some edema; or, a definite decrease in kidney function; or, hypertension at least 40 percent disabling under Diagnostic Code 7101. An 80 percent rating is assigned for persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. Lastly, a 100 percent rating is assigned when renal dysfunction requires regular dialysis, or precludes more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. Turning to the evidence of record, the Board first notes that there are 4 VA examination reports associated with the claims file relevant to the Veteran's increased rating claim. Firstly, during a January 2011 VA examination, a VA examiner noted that edema of the Veteran's extremities was not present. Urinalysis testing was performed, and the examiner stated that protein (micro albuminuria) and sugar were present. However, the examiner also indicated that the Veteran's urinalysis was absent red blood cells, hyaline casts, and granular casts. The examiner diagnosed the Veteran with diabetic nephropathy and remarked that this disability caused secondary to decreased functional reserve capacity. Next, the Board notes that diagnostic testing results relevant to the Veteran's diabetic nephropathy were included within a May 2016 VA hypertension examination report. Specifically, the VA examiner noted that the Veteran had an elevated albuminuria of 31.8, creatinine of 1.2 mg/dl, and eGFR less than 60 ml/min. However, the examiner remarked that this was normal and was more indicative of dehydration. Relatedly, in May 2016, the Veteran was also provided a VA kidney conditions examination. During this examination, the Veteran stated that he did not take continuous medication for his diabetic nephropathy. The examiner remarked that the Veteran did not have renal dysfunction and noted that laboratory studies performed in March 2016 showed a BUN level of 16; creatinine of 1.2. Additionally, the examiner commented that urinalysis was negative for hyaline casts and granular casts, and red blood cells, but positive for albumin. Lastly, in August 2019, the Veteran underwent a VA kidney conditions examination. On this occasion, the Veteran was provided a diagnosis of chronic kidney disease. Despite providing this diagnosis, the examiner remarked that Veteran and his spouse indicated that they were never told that the Veteran had kidney disease. In reviewing the Veteran's claims file in conjunction with providing the examination, the examiner stated that the Veteran began displaying an elevated microalbumin/creatinine ratio on May 12, 2017 The examiner next stated that the Veteran did not currently have renal dysfunction. The examiner then indicated that there was trace edema in the right and left lower extremities. Lastly, the examiner commented that laboratory studies were performed, and that the Veteran had: a BUN level of 24, creatinine of 1.24 mg/dl, and normal eGFR. Separate from the VA examination reports of record, the Board observes that medical treatment records associated with the claims file contain evidence relevant to the Veteran's increased rating claim. Specifically, in a November 2011 discharge summary from the DeKalb Medical Center, it was noted that the Veteran's BUN level was 11 and his creatinine was 1.3. Additionally, in materials received from the DeKalb Medical Physicians Group, macroscopic albuminuria was mentioned as a comorbidity of diabetes in treatment records from September 2014, July 2015, May 2016, October 2018, and February 2019. In contrast with these notations, the following relevant laboratory results were recorded in the same treatment records from the DeKalb Medical Physicians Group: albumin 1+ in October 2013; BUN level of 19 in May 2015; BUN level of 20 in October 2014; BUN level of 19 in April 2015; BUN level of 20 in July 2015; BUN level of 20 in October 2015; and creatinine of 1.11 in October 2016. From this evidence of record, the Board finds that, unlike the October 2020 rating decision which assigned the 60 percent rating, the Veteran first displayed a definite decrease in kidney function on May 12, 2017not August 28, 2019. Accordingly, the Board grants the Veteran's claim and assigns an increased 60 percent rating, effective May 12. 2017. See 38 C.F.R. §§ 3.400(o)(1), 4.115a. In assigning this 60 percent rating effective May 12, 2017, the Board also concludes that, prior to this date, the Veteran's diabetic nephropathy did not cause such impairment as to be compensable under 38 C.F.R. § 4.115a. Specifically, although albumin was recurring during the time period prior to May 12, 2017, it was not present with hyaline and granular casts or red blood cells. Further, edema was not noted until the August 2019 VA examination and, as explained previously, the Veteran's hypertension was not compensable under Diagnostic Code 7101. In addition, the Board also declines to assign a rating greater than 60 percent for any portion of the claim period. Specifically, the Veteran did not display persistent edema and albuminuria with BUN 40 to 80 mg%, or creatinine 4 to 8 mg% during any portion of the appeal period. Moreover, a medical professional did not associate the Veteran's diabetic nephropathy with generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion at any point during the appeal period. Such evidence is necessary for the assignment of the next higher rating of 80 percent under 38 C.F.R. § 4.115a. Accordingly, to this extent, the Board denies the Veteran's claim. Service Connection for a Low Back Disability As a general matter, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection generally requires credible and competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Moving to the evidence of record, the Board first finds that the Veteran has a current low back disability. See October 2020 VA Back Conditions Examination (providing diagnoses of degenerative arthritis of the spine and status post lumbar fusion surgery). Accordingly, the Board finds the first service connection requirementcurrent disabilityto be satisfied in the instant case. Turning to the next requirement of an in-service incurrence, while the Veteran's service treatment records (STRs) do not document an in-service back injury or document treatment for the Veteran's low back, the Veteran testified in May 2017 that his in-service duties as a quartermaster and working in a medical depot in Vietnamwhich routinely required heavy liftingcontributed to the current condition of his low back. See Hearing Tr. at 30-31. The Veteran also stated that he did seek treatment for his back in service as he was young and felt that his symptoms were not severe enough at that time to prevent him from doing his job. Id. at 35-36. A review of the Veteran's service personnel records (SPRs) show that the Veteran had principal duties in service as a supply handler, warehouse specialist, general warehouseman, and medical equipment repairman. As a layperson, the Veteran is competent to report and describe his in-service experiences. See Layno v. Brown, 6 Vet. App. 465 (1994). The Board finds the Veteran's reports about his in-service duties to be credible in the instant case. As such, the Board finds the in-service incurrence requirement for service connection to also be satisfied in the instant case. Lastly, regarding the remaining requirement of nexus, the Board notes that there are 2 competent medical opinions of record addressing the etiology of the Veteran's low back disability. Firstly, in August 2019, a VA examiner provided an opinion as to the etiology of the Veteran's current diagnoses of degenerative arthritis of the spine and status post lumbar fusion surgery. The examiner opined that the Veteran's diagnosed conditions were associated with the normal aging process. The examiner explained that the medical literature provided that as people age, the water and protein content of the cartilage of the body result in weaker, more fragile, and thin cartilage, causing gradual deterioration of discs in the spine. The examiner then directly addressed the Veteran's circumstances and stated that, during the examination, the Veteran reported that his back problems began in 2005about 39 years after separation for service. Lastly, the examiner stated that while the Veteran may have engaged in heavy lifting in service, an injury from heavy lifting activity would not manifest about 40 years later. Rather, the examiner explained, the Veteran separated from service at the age of 25 and most likely engaged in physical activities throughout his early adulthood years. In addition to the August 2019 opinion, another VA medical professional provided an etiological opinion in October 2020. The October 2020 professional opined that a nexus to service could not be established because there was no objective evidence to support a finding that the Veteran injured his low back in service. Additionally, the professional remarked that the Veteran's first chronicled low back complaint occurred over 38 years after service. In reviewing both of these medical opinions, the Board first finds the October 2020 opinion, with respect to the issue of service connection on a direct basis, to be inadequate for adjudicative purposes. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Specifically, the October 2020 opinion did not contain much explanatory rationale and did not engage with the Veteran's lay testimony concerning his performance of in-service heavy lifting duties. Accordingly, the Board finds if of lesser probative value. Comparatively, the Board finds the August 2019 opinion to be adequate for adjudicative purposes as it was based on a consideration of the Veteran's entire medical history, described the Veteran's condition in detail, and included an explanatory rationale in support of its conclusion that the Veteran's current low back diagnoses were products of the aging process and not related to his in-service duties. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Accordingly, as there are no competent, adequate medical opinions of record linking a current low back disability to service, entitlement to service connection is denied. See 38 C.F.R. § 3.303. In denying the Veteran's claim, the Board also acknowledges that, in its April 2019 remand, the Board requested that a VA medical professional address a contention raised by the record that the Veteran's current low back disability was related to in-service exposure to herbicide agents. As mentioned previously, the Veteran served in the Republic of Vietnam and, accordingly, VA has presumed that he was exposed in service to herbicide agents. See 38 C.F.R. § 3.307(a)(6)(iii). 38 C.F.R. § 3.309(e) recognizes that certain disabilities have been associated with in-service exposure to herbicide agents and, thusly, are entitled to service connection on a presumptive basis. However, none of the Veteran's diagnosed low back disabilities are included within the presumptive list provided by 38 C.F.R. § 3.309(e). Nevertheless, service connection may still be warranted on a direct basis for the low back if adequate, competent evidence links the diagnosed low back disability to in-service herbicide exposure. 38 C.F.R. § 3.303(a). In addressing the Veteran's herbicide exposure, the August 2019 VA examiner stated that back conditions were "not an Agent Orange presumptive condition." The Board finds this opinion concerning herbicide exposure to be inadequate as it did not address whether service connection based on in-service herbicide agent exposure was warranted regardless of the low back not being included on the 38 C.F.R. § 3.309(e) presumptive list. Accordingly, the Board finds the August 2019 opinion with respect to this limited question to be inadequate for adjudicative purposes. See Nieves-Peake, supra. Thereafter, the October 2020 VA medical professional also addressed the Veteran's in-service herbicide agent exposure and its connection to any current low back disability. Specifically, the October 2020 professional stated that the Veteran's presumed exposure to herbicide agents in Vietnam was not a risk factor for "late onset of degenerative changes" over 30 years after separation from service. Unlike the portion of the opinion addressing service connection on a direct basis in relation to the Veteran's in-service occupational duties, the Board finds the October 2020 opinion addressing herbicide agent exposure to be adequate for adjudicative purposes. See Stefl, supra. Specifically, based on her understanding and expertise, the October 2020 professional opined that herbicide agent exposure was not a risk factor for the development of degenerative changes in the spine over 20 years after service. As there is no competent, adequate opinion of record linking the Veteran's currently diagnosed low back disabilities to service, the Board concludes that service connection as due to herbicide exposure is also not warranted in the instant case. See 38 C.F.R. §§ 3.303, 3.307, 3.309. REASONS FOR REMAND 1. Increased Ratings for Peripheral Neuropathy of the Bilateral Lower and Upper Extremities Although the Board regrets the additional delay, it finds that remand of these increased rating issues is warranted so that the Veteran may be provided an additional VA examination. Specifically, in April 2019, the Board remanded these issues for the Agency of Original Jurisdiction (AOJ) to schedule and perform an updated VA examination. Following the Board's remand, 2 separate VA examination reports were completed concerning the Veteran's lower and upper extremities. An August 2019 examination report indicated that the Veteran did not have any peripheral neuropathy or peripheral nerve condition in the diagnosis section of the report. However, in the Remarks section, the examiner stated that the VA's prior diagnoseswhich were already service-connectedwere confirmed. Comparatively, in a separate VA examination report for diabetic sensory-motor peripheral neuropathy completed on the same date, diabetic peripheral neuropathy was listed as a current disability. The Board finds the information listed in the examination reports to be in conflict such that an additional remand is warranted so that a new, clarifying VA examination may be provided for the Veteran. 2. TDIU Similarly, the Board finds that the issue of entitlement to a TDIU must also be remanded due to lack of substantial compliance with the April 2019 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Specifically, in its April 2019 remand directives, the Board requested that the AOJ provide the Veteran a VA opinion which addressed the functional effects of the Veteran's service-connected disabilities on his ability to obtain or maintain substantially gainful employment, including what functions or types of employment would be precluded compared to those which would still be feasible. The requested opinion was provided in August 2019. However, the VA medical professional merely opined that the Veteran's service-connected disabilities "[did] not limit his ability to function in an occupational environment." The ultimate responsibility for a TDIU determination is a factual matter rather than a medical question and is an adjudicative determination made by the Board or the AOJ. See Floore v. Shinseki, 26 Vet. App. 376, 381 (2013) (observing that "medical examiners are responsible for providing a 'full description of the effects of disability upon the person's ordinary activity,' but it is the rating official who is responsible for 'interpret[ing] reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may actually reflect the elements of disability present'"). Accordingly, as the August 2019 professional did not address the functional effects of the Veteran's disabilities and only opined as to employability directly, the Board finds that remand is warranted for the provision of an additional VA medical opinion. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination with an appropriate clinician to determine the current nature and severity of his service-connected peripheral neuropathies of the upper and lower extremities. The entire claims fileincluding a copy of this remandmust be made available to the examiner for review. The examination should be conducted in accordance with the current examination worksheet or disability benefits questionnaire (DBQ). The clinician should consider medical and lay evidence of record when providing any opinion in conjunction with the examination. If an opinion is provided, it must be accompanied by a complete rationale. If the clinician cannot provide an opinion without resorting to speculation, he or she should explain why an opinion cannot be provided (e.g., lack of sufficient information/evidence, the limits of medical knowledge, etc.). 2. After Item (1) has been completed to the extent possible, send the Veteran's claims file to an appropriate VA clinician to issue a medical opinion regarding the functional effects of the Veteran's service-connected disabilities. The entire claims file, including a copy of this Remand, must be made available to and must be reviewed by the clinician. If the clinician determines that an examination should be conducted, one should be scheduled. Thereafter, the clinician should comment upon the functional effects of the Veteran's service-connected disabilities. The examiner should describe the limitations and restrictions imposed by the service-connected disabilities on routine work activities, such as interacting with customers/coworkers and using technology, plus other physical activities such as sitting, standing, walking, lifting, carrying, pushing, and pulling, and mental activities such as understanding and remembering instructions, and sustained concentration. Additionally, the clinician should address the types of work and tasks that could be precluded and those that could remain feasible. In providing a response to the above prompt, the clinician should not consider any nonservice-connected disabilities or the Veteran's age. Additionally, in providing a response to the above prompt, the clinician is reminded that the Veteran is currently service connected for the following disabilities: (a.) Diabetes mellitus type 2; (b.) Diabetic nephropathy; (c.) Persistent depressive disorder with anxious distress; (d.) Left ventricular hypertrophy and cardiomegaly associated with diabetes mellitus; (e.) Peripheral neuropathy of the bilateral upper extremities; (f.) Peripheral neuropathy of the bilateral lower extremities; (g.) Hypertension; and (h.) Erectile dysfunction. In offering any opinion, the clinician should consider medical and lay evidence of record. The clinician must provide a complete rationale for any opinion rendered. If the clinician cannot provide an opinion without resorting to speculation, he or she should explain why an opinion cannot be provided (e.g., lack of sufficient information/evidence, the limits of medical knowledge, etc.). S.C. KREMBS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N.S. Pettine, 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.