Citation Nr: 22010490 Decision Date: 02/23/22 Archive Date: 02/23/22 DOCKET NO. 18-05 908A DATE: February 23, 2022 ORDER Entitlement to service connection for right lower extremity peripheral neuropathy (PN) is granted. Entitlement to service connection for left lower extremity PN is granted. REMANDED Entitlement to service connection for a respiratory disability is remanded. FINDING OF FACT The Veteran has PN of the right and left lower extremities that is caused or aggravated by his service-connected diabetes mellitus (DM). CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for right lower extremity PN have been met. 38 U.S.C. §§ 1110, 1112, 5107 (2018); 38 C.F.R. §§ 3.102, 3.310 (2020). 2. The criteria for entitlement to service connection for left lower extremity PN have been met. 38 U.S.C. §§ 1110, 1112, 5107 (2018); 38 C.F.R. §§ 3.102, 3.310 (2020). REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veteran had active military service from June 1969 to April 1971, to include service in the Republic of Vietnam. These matters come before the Board of Veterans' Appeals (Board) on appeal from March 2017 and June 2017 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). In October 2021, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the record The Veteran has contended that he was diagnosed with PN of the right and left lower extremities which is secondary to his service-connected DM. In August 2014, the Veteran's feet were evaluated at a VA medical center (VAMC). He complained of burning in his toes and balls of his feet. A VAMC podiatrist concluded that the Veteran had DM with neuropathy. The Veteran was afforded a VA examination in March 2015. The examiner found no objective evidence of diabetic PN. The examiner stated that the Veteran reported subjective symptoms in both lower extremities predating his DM diagnosis in June 2013 by many years. The examiner noted that the Veteran's symptoms were likely referred from the back. The examiner added that the Veteran had a history of vitamin B12 deficiency which could be associated with symptoms even though it affected the posterior column in the cord [central, not peripheral]. The examiner commented that the Veteran has had excellent control of his DM since his diagnosis, which would not likely be associated with peripheral neuropathy at the time. A review of the Veteran's VAMC records reflected that he has underwent further evaluation for diabetic PN. In August 2015, a VAMC podiatrist remarked in response to the March 2015 VA examiner's findings that neuropathic symptoms were commonly found in diabetic patients and had not yet progressed to the point of loss of protective sensation. The VAMC podiatrist added that a large percentage of patients have neuropathic symptoms before the diagnosis of diabetes. The VAMC podiatrist noted that the Veteran had had symptoms for the last 5 to 10 years. While an April 2018 EMG revealed no evidence of large fiber peripheral neuropathy involving either lower limb, a VAMC physician noted that small fiber sensory neuropathy could not be ruled out by standardized nerve conduction study techniques. Further, the April 2018 EMG showed no evidence of back-related radiculopathy involving either lower limb. Therefore, the Board finds that the evidence for and against the claim is in approximate balance. Accordingly, the benefit of the doubt must be resolved in favor of the Veteran, and entitlement to service connection for PN, right and left lower extremity, is warranted. 38 U.S.C. § 5107(b) (2018); Lynch v. McDonough, 2021 U.S. App. LEXIS 37307 (Dec. 17, 2021). REASONS FOR REMAND The Veteran has asserted that his respiratory disability is related to his active service. Service treatment records (STRs) showed that the Veteran had a history of chest pain, bloody sputum, and cough. In January 1971, he reported smoking 1 1/2 packs per day (PPD). He was diagnosed with smoker's cough. At his February 1971 separation examination, the Veteran complained of chest pain again. However, the service examiner determined that there was no pathology. In May 2017, the Veteran was afforded a VA examination. The examiner found that the Veteran had steroid responsive interstitial lung disease (ILD). In a March 2018 VA medical opinion, the examiner opined that the Veteran's ILD was less as likely as not related to his active service. The examiner found no evidence of a respiratory disability until 2009, approximately 38 years post-service. The VAMC records documented the Veteran's history and frequency of tobacco use and noted that he reportedly quit smoking in 1972 or 1975. The examiner noted that current medical literature did not show that the Veteran's subjective symptoms and chest X-ray findings during service were consistent with ILD. The examiner explained that ILD is a term associated with a group of diffuse parenchymal lung diseases. These conditions could be divided into those that are idiopathic and those associated with known causes such as infections, environmental exposures (including smoking), sarcoidosis, and pneumonias. In October 2021, a VAMC pulmonary physician stated that pulmonary function test (PFT) results conducted in August 2021 revealed that the Veteran had restrictive lung disease (RLD). The VAMC pulmonary physician opined that the Veteran's RLD was at least as likely as not related to his exposure to herbicides in the Republic of Vietnam. The VAMC physician acknowledged that the Veteran reportedly smoked 1/4 PPD for five years and quit in 1971. However, the VAMC physician did not know of any other risk factors for the development of the Veteran's RLD other than his herbicide exposure. In light of the conflicting diagnoses of record, the Board finds that the Veteran should be afforded an additional VA examination to determine the nature and etiology of any currently present respiratory disability. Upon remand, any outstanding treatment records from Malcom Randall VAMC, to specifically include the August 2021 PFT results, should be identified and obtained. The matters are REMANDED for the following action: 1. Identify and obtain any pertinent, outstanding VA and private treatment records, to specifically include August 2021 pulmonary function test results from Malcom Randall VAMC, and associate them with the claims file. 2. Then, schedule the Veteran for a VA examination to determine the nature and etiology of any currently present respiratory disability. The claims file must be made available to and reviewed by the examiner. Any indicated studies should be performed. Based on the examination results and the review of the record, the examiner should first identify all respiratory disabilities present during the pendency of the claim, or proximate thereto. Then, for each respiratory disability identified, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent or better probability) that the respiratory disability had its onset during the Veteran's active service, or is otherwise etiologically related to such service. The examiner must address service treatment record notations and conflicting diagnoses for interstitial and restrictive lung diseases. A rationale for all opinions expressed must be provided. 3. Confirm that VA examination report and all medical opinions provided comport with this remand, and undertake any other development determined to be warranted. 4. Then, readjudicate the remaining claim on appeal. If the decision remains adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Ware, 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.