Citation Nr: 21042654 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 16-20 459 DATE: July 13, 2021 REMANDED The issue of service connection for a head disorder, to include traumatic brain injury (TBI), is remanded. The issue of service connection for a neck disorder is remanded. The issue of service connection for a low back disorder, as secondary to a neck disorder, is remanded. The issue of service connection for a heart disorder, to include ischemic heart disease (IHD), is remanded. The issue of service connection for diabetes mellitus type 2 (DM), to include as due to herbicide agent exposure, is remanded. The issue of service connection for bilateral upper and lower extremity peripheral neuropathy, as secondary to DM, is remanded. The issue of service connection for erectile disfunction (ED), as secondary to DM, is remanded. REASONS FOR REMAND The Veteran had active service from July 1969 to July 1971. 1. The issue of service connection for a head disorder, to include TBI, is remanded. 2. The issue of service connection for a neck disorder is remanded. 3. The issue of service connection for a low back disorder, as secondary to a neck disorder, is remanded. 4. The issue of service connection for a heart disorder, to include IHD, is remanded. 5. The issue of service connection for DM, to include as due to herbicide agent exposure, is remanded. 6. The issue of service connection for bilateral upper and lower extremity peripheral neuropathy, as secondary to DM, is remanded. 7. The issue of service connection for ED, as secondary to DM, is remanded. The matters are REMANDED for the following action: 1. BACKGROUND FOR THE RO ADJUDICATOR: The Board of Veterans' Appeals (Board) in part denied the appeal in May 2020. In April 2021, the Court of Appeals for Veterans Claims (Court) vacated the Board's denial of the appeal, and remanded the issues now before the Board under a Joint Motion for Remand filed by the Veteran through counsel and VA. In part, the April 2021 JMPR directed the Board to ensure the duty to assist to obtain both VA and private treatment records was satisfied. The JMPR also noted VA was required to provide an adequate statement of reasons and basis regarding the issues of service connection for a neck disorder, a heart disorder, and for DM. THE REMAND DIRECTIVES FOLLOW. 2. Obtain ALL outstanding VA treatment records, to include from October 2016 to the present, and associate them with the Veteran's claims file. All efforts to obtain the records MUST be documented in the claims file. 38 C.F.R. §§ 3.159(c)(2), (c)(3). Special attention MUST be given to the following: * In a May 2015 VA male reproductive system conditions examination, the examiner noted review of March 13, 2009, and April 2009 treatment records. However, the referenced 2009 treatment records are not in the claims file. * An October 2016 VA primary care note references a March 13, 2009 diagnosis of hypogonadism by Dr. W.L.F. However, the referenced March 2009 treatment record is not in the claims file. * April 13, 2009 and June 11, 2009 VA treatment records show that brain MRI and bone density and mineral analyses were requested by Dr. W.L.F. However, the referenced requested reports are not in the claims file. * In April 2017, the Veteran stated that he received treatment for his neck disorder at the Kansas City VA Medical Center. However, VA records from October 2016 to the present are not in the claims file. 3. Make ALL reasonable efforts to obtain ALL relevant private treatment records, to include those referenced below, and associate them with the Veteran's claims file. All efforts to obtain the records MUST be documented in the claims file. 38 C.F.R. §§ 3.159(c)(1), (e)(2). Special attention MUST be given to the following: * The Veteran reported treatment with Dr. G. in Nevada, MO, in 1975 or 1976 for neck pain. * The Veteran reported treatment with Dr. W., a neurosurgeon in Springfield, MO, who performed a computerized tomography (CT) scan of the neck in the early 1980s. * The Veteran reported treatment with two different physicians (both Dr. G., but not Dr. G. referenced for care in 1975/1976 and 1995) at the Nevada Medical Mall in Nevada, MO, in 1980. * The Veteran reported physical therapy at El Dorado Springs Hospital in El Dorado Springs, MO. * The Veteran reported treatment with Dr. G. (same Dr. G. as referenced for treatment in 1975/1976) in Joplin, MO, who performed neck surgery in 1995. * An October 2016 VA treatment record indicates that the Veteran established treatment with Dr. L., a primary care physician, every four months for his neck condition in Nevada, MO, and Dr. D., a cardiologist, at Mercy Hospital in Joplin, MO. All attempts to obtain these records and all responses received MUST be documented in the record. The Veteran MUST be notified of the status of all requests for information. 4. After completion of the above directed records development, schedule the Veteran for a VA examination to determine the nature and etiology of any neck disorder. All indicated tests and studies should be accomplished and the findings reported in detail. All relevant medical records must be made available to the examiner for review of pertinent documents. The examination report should specifically state that such a review was conducted. The examiner must provide a comprehensive explanation for all opinions provided. The examiner must address the following: (a.) Identify all currently diagnosed neck disorders. (b.) Provide an opinion as to whether any currently diagnosed neck disorder is etiologically related to the Veteran's service. (c.) The examiner MUST address and discuss, in detail, the Veteran's reported ongoing treatment since 1971, to include as outlined below, and all newly obtained medical records because of the additional development directed by his remand. (d.) THE EXAMINER MUST ALSO EXPRESS AN OPINION OF WHETHER THE VETERAN'S ACCOUNT OF THE DEVELOPMENT OF THE DISORDER IS CONSISTENT WITH THE MEDICAL EVIDENCE AND THE EXAMINER'S KNOWLEDGE AND PRACTICE EXPERIENCE. (e.) If the examiner finds that any currently diagnosed neck disorder is not etiologically related to the Veteran's service, to the extent possible, provide an opinion as to the nature of onset. The examiner's attention is drawn to the following: * All records associated with the file because of this remand. * In the September 2016 VA examination, the Veteran reported having neck pain since the 1970s. He reported medical treatment for his neck condition beginning in 1975 or 1976, which culminated in a discectomy in 1995. The examiner diagnosed cervical degenerative disc disease with radiculopathy, with a date of diagnosis of 1995. * In a November 2016 statement, the Veteran reported medical treatment between 1971 and 1980, and that he treated his neck pain with over-the-counter medications and sample prescriptions from treating physicians. He reported that, after acquiring health insurance in 1980, he was treated by several other physicians. 5. After completion of the above directed records development, schedule the Veteran for a VA examination to determine the nature and etiology of any heart disorder. All indicated tests and studies should be accomplished and the findings reported in detail. All relevant medical records must be made available to the examiner for review of pertinent documents. The examination report should specifically state that such a review was conducted. The examiner must provide a comprehensive explanation for all opinions provided. The examiner must address the following: (f.) Identify all currently diagnosed heart disorders. (g.) Provide an opinion as to whether any currently diagnosed heart disorder is etiologically related to the Veteran's service. (h.) If the examiner finds that any currently diagnosed heart disorder is not etiologically related to the Veteran's service, to the extent possible, provide an opinion as to the nature of onset. The examiner's attention is drawn to the following: * All records associated with the file because of this remand. * In September 2013, the Veteran was diagnosed with tachycardia. * In December 2014, the Veteran was diagnosed with paroxysmal supraventricular tachycardia. * In the May 2015 VA examination, the examiner noted a diagnosis for supraventricular arrhythmia, but found that the Veteran does not have IHD. The examiner did not provide an etiological opinion as to any heart condition. 6. After completion of the above directed records development, schedule the Veteran for a VA examination to determine the nature and etiology of any past or current diagnosis of DM. All indicated tests and studies should be accomplished and the findings reported in detail. All relevant medical records must be made available to the examiner for review of pertinent documents. The examination report should specifically state that such a review was conducted. The examiner must provide a comprehensive explanation for all opinions provided. The examiner must address the following: (i.) The examiner is ADVISED that September 2013 and December 2014 VA medical records show treatment for DM, to include the use of Metformin. (j.) Given the medical record of past treatment for DM, the examiner is asked to address and discuss, in detail, the Veteran's past and current treatment for DM, and opine as to whether the Veteran has ever had, or currently has a diagnosis of DM. (k.) If the examiner determines that the Veteran has ever had a diagnosis of DM and/or currently has a diagnosis of DM, in either or both cases, the examiner MUST opine as to the likely etiology of the Veteran's diagnosis. (l.) If the examiner determines that any past or current DM diagnosis is not etiologically related to the Veteran's service, to the extent possible, provide an opinion as to the nature of onset. (m.) If the examiner determines that the Veteran has never had a diagnosis of DM, the examiner MUST discuss the record fully, paying close attention to record of treatment for DM in September 2013 and December 2014. The examiner's attention is drawn to the following: * All records associated with the file because of this remand. * A September 2013 VA treatment record noted treatment for DM and the use Metformin twice daily. * A December 2014 VA medical record noted that the Veteran's DM is "well controlled." * In the May 2015 VA examination, the examiner noted diagnoses for metabolic syndrome and glucose intolerance, but not DM. The examiner noted diagnostic testing conducted in March 2015 and concluded that "[the Veteran] has never been diagnosed with DM type 2." However, the examiner relied on an inaccurate factual premise, which is that the Veteran had never been diagnosed with DM. Instead, the record shows that the Veteran has been treated for DM and had used the medication, Metformin, to control his condition. Therefore, the May 2015 VA examination is inadequate for rating purposes. 7. After completion of the above directed records development, to include new VA examinations for a neck disorder and DM, IF NECESSARY, accomplish any or all of the following: (n.) Schedule the Veteran for a VA examination to determine whether any head disorder is related to his service. (o.) Schedule the Veteran for a VA examination to determine whether any low back disorder is related to his neck disorder. (p.) Schedule the Veteran for a VA examination to determine whether he has bilateral upper and/or lower peripheral neuropathy that is related to his DM. (q.) Schedule the Veteran for a VA examination to determine whether he has ED that is related to his DM. The examiner must provide a thorough explanation for the requested opinions. If the examiner cannot provide the requested opinions without resorting to speculation, s/he should expressly indicate this and provide supporting rationale as to why the opinions cannot be made without resorting to speculation. The examiner is advised that by law, the mere statement that the claims folder was reviewed and/or the examiner has expertise is not sufficient to find the examination/opinion sufficient. 8. Following the review and any additional development deemed necessary, re-adjudicate the claims. Should the claims not be granted in their entirety, issue an appropriate supplemental statement of the case (SSOC) and forward the claims to the Board for adjudication. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Timothy T. Emmart 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.