Citation Nr: 22016001 Decision Date: 03/21/22 Archive Date: 03/21/22 DOCKET NO. 14-29 105 DATE: March 21, 2022 ORDER Entitlement to a disability rating in excess of 10 percent for hypertension is denied. Entitlement to a disability rating in excess of 40 percent for diabetes mellitus, type II, to include erectile dysfunction, is denied. REMANDED Entitlement to service connection for sleep apnea, to include as secondary to service-connected disability, is remanded. Entitlement to service connection for arthritis, to include as secondary to service-connected diabetes mellitus, type II, is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for bilateral plantar fasciitis is remanded. Entitlement to a disability rating in excess of 40 percent for peripheral neuropathy, right hand, is remanded. Entitlement to a disability rating in excess of 30 percent for peripheral neuropathy, left hand, is remanded. Entitlement to a disability rating in excess of 20 percent for peripheral neuropathy, left lower extremity, is remanded. Entitlement to a disability rating in excess of 20 percent for peripheral neuropathy, right lower extremity, is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance is remanded. FINDINGS OF FACT 1. Throughout the relevant rating period, the Veteran's service-connected hypertension has not been manifested by diastolic pressure that is predominantly 110 or more or by systolic pressure that is predominantly 200 or more. 2. Throughout the relevant rating period, the Veteran's diabetes mellitus, type II, to include erectile dysfunction, was manifested by the requirement for insulin and restricted diet, and regulation of activities. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for the service-connected hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.14, 4.21, 4.104, Diagnostic Codes 7101. 2. The criteria for entitlement to a rating in excess of 40 percent for diabetes mellitus, type II, to include erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.14, 4.21, 4.119, Diagnostic Code 7913. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1968 to March 1971. These matters come before the Board of Veterans' Appeals (Board) on appeal of a June 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran submitted a Notice of Disagreement (NOD) to the June 2012 rating in August 2012. The record does not include a Statement of the Case (SOC) in response to the June 2012 NOD. However, a Report of General Information dated in October 2017 documents that the Veteran received a hard copy of a September 2012 SOC. The Veteran submitted his Substantive Appeal in June 2013, within a couple of days of the deadline for submitting a Substantive Appeal. See 38 C.F.R. § 19.52(b)(1). The June 2012 rating decision denied entitlement to increased ratings for bilateral upper extremity and bilateral lower extremity peripheral neuropathy. In the August 2012 NOD the Veteran appealed the June 2012 rating decision's denial of increased ratings for bilateral upper and lower extremity peripheral neuropathy. In the June 2013 substantive appeal, which was received within the one-year appeal period following the June 2012 rating decision, the Veteran again appealed the denial of increased ratings for bilateral upper and lower extremity peripheral neuropathy. As noted above, the September 2012 SOC is not associated with the record. However, the record reflects that the Veteran appealed the June 2012 rating decision in his August 2012 NOD and June 2013 substantive appeal. As such, the Board finds that the Veteran perfected an appeal to the Board of the issues of entitlement to increased ratings for bilateral upper and bilateral lower extremity peripheral neuropathy and the issues are properly before the Board. This case was previously remanded by the Board in September 2019. The case has been returned to the Board for review. The Veteran was in receipt of TDIU from July 27, 2007, to October 23, 2008, the date his combined rating for the service-connected disabilities became 100 percent. However, the grant of a TDIU is not the same as a schedular 100 percent disability rating, and the award of a TDIU in addition to the award of a schedular 100 percent rating may result in the payment of additional benefits. See Buie v. Shinseki, 24 Vet. App. 242 (2011). As such, the issue of entitlement to a TDIU was not rendered moot by the grant of a 100 percent schedular rating and is on appeal as part of the increased rating issues. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In a November 2021 statement, the Veteran's daughter reported that the Veteran needs an aide for walking, talking, and holding onto a cup. She further reported that the "list of assisting with daily functions is extensive." In light of the Veteran's daughter's assertions and the other evidence of record, the Board finds that the issue of entitlement to SMC based on the need for regular aid and attendance is reasonably raised by the record and is part and parcel of the increased rating claims. See Akles v. Derwinski, 1 Vet. App. 118, 121 (1991) (stating that the issue of entitlement to SMC is part and parcel of a claim for increased compensation and does not require submission of a separate claim); 38 C.F.R. § 3.155(d)(2). Increased Rating Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings shall be applied, the higher rating 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. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," in all claims for increased ratings. Hart v. Mansfield, 21 Vet. App. 505, 519 (2007). 1. Entitlement to a higher disability rating for hypertension is denied. The Veteran seeks a higher rating for his service-connected hypertension. The Veteran's service-connected hypertension is rated as 10 percent disabling under 38 C.F.R. § 4.104, Diagnostic Code 7101. The Veteran's increased rating claim was received on November 19, 2009. Therefore, the relevant rating period is from November 20, 2008, one year prior to receipt of the claim, through the present. See 38 C.F.R. § 3.400(o)(2). Under Diagnostic Code 7101, a 10 percent rating is warranted for diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted for diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more. Higher ratings, up to a maximum 60 percent, are warranted where there are diastolic pressure readings that are predominantly 120 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. The Board has carefully reviewed all of the relevant medical evidence of record and finds that none show a systolic reading of 200 or above or that the Veteran has had diastolic pressure readings that were predominantly 110 or more at any point during the relevant rating period. A March 2009 VA treatment record reflects blood pressure readings of 140/82 and 163/95. The Veteran was provided a VA examination related to his hypertension in September 2009. At the September 2009 VA examination the Veteran had blood pressure readings of 136/74, 132/72, and 136/74. The Veteran was provided a VA hypertension examination in August 2011. The VA examiner noted that the Veteran takes medication related to his hypertension. Upon examination, the Veteran's blood pressure was 110/70. The Veteran was provided a VA examination related to his hypertension in November 2020. Upon examination, the Veteran demonstrated blood pressure readings of 140/80, 150/90, and 150/90. Having reviewed the complete record, the Board finds that the evidence does not support the criteria for a disability rating in excess of 10 percent during the period on appeal for hypertension under Diagnostic Code 7101. The evidence shows no evidence of diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. In making its determinations in this case, the Board has carefully considered the Veteran's contentions with respect to the nature and severity of his service-connected hypertension at issue. The Board notes that his lay testimony is competent to describe certain symptoms associated with this disability. His history and symptom reports have been considered, including as presented in the medical evidence discussed above, and are noted to be contemplated by the criteria for the disability rating for which he has been found entitled by the Board. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disability at issue. As such, while the Board accepts the Veteran's statements with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected condition at issue. The Board therefore finds that the criteria for a rating in excess of 10 percent for the Veteran's service-connected hypertension have not been met at any time during the rating period. Accordingly, there is no basis for staged ratings of the Veteran's hypertension pursuant to Hart, 21 Vet. App. at 519, and a higher rating must be denied. As the evidence persuasively weighs against the Veteran's claim, the benefit-of-the-doubt doctrine is not for application, and the claim must be denied. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990); Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 2. Entitlement to a higher disability rating for diabetes mellitus, type II is denied. The Veteran seeks a higher rating for his service-connected diabetes mellitus, type II, to include erectile dysfunction. The Veteran's service-connected diabetes mellitus is rated as 40 percent disabling under 38 C.F.R. § 4.119, Diagnostic Code 7913. The Veteran's increased rating claim was received on November 19, 2009. Therefore, the relevant rating period is from November 20, 2008, one year prior to receipt of the claim, through the present. See 38 C.F.R. § 3.400(o)(2). Under 38 C.F.R. § 4.119, Diagnostic Code 7913, diabetes requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately rated, warrants a 100 percent rating. Diabetes requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately rated, warrants a 60 percent rating. Diabetes requiring insulin, restricted diet, and regulation of activities warrants a 40 percent rating. Compensable complications of diabetes are separately rated unless they are part of the criteria used to support a 100 percent rating. Noncompensable complications are considered part of the diabetic process. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1). The criteria for the progressively increasing ratings for diabetes are stated in the conjunctive rather than the disjunctive. As such, each level of increase in the rating requires additional criteria to those for the lower rating, which must also be met to warrant the increase. See Camacho v. Nicholson, 21 Vet. App. 360, 363-64 (2007). Turning to the relevant evidence of record, the Veteran's VA treatment records confirm that he was prescribed insulin and medication to manage his diabetes and that he has been given dietary restrictions related to his diabetes. They also show that he was instructed to regulate his activity level as tolerated as a way to help manage his diabetes. However, they do not reflect that the Veteran had episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately rated. The Veteran was provided a VA examination in September 2009. The VA examiner noted that the Veteran takes insulin related to his diabetes mellitus, type II. The Veteran reported that he tries to be compliant with a low-carbohydrate, low-fat diet and that his weight has not fluctuated much in the past twelve months. He further reported that the main restrictions on activities are related to his inability to exercise or run. The Veteran reported that he visits his primary care provided once to twice per month and that he not been seen for ketoacidosis or hyperglycemic reactions. The Veteran was provided a VA examination in May 2016. The VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The VA examiner noted that the Veteran requires insulin injections more than once per day. Additionally, the Veteran did not require regulation of activities as part of medical management of his diabetes mellitus, type II. The Veteran visited his diabetic care provider less than two times per month. The Veteran did not require hospitalizations for episodes of ketoacidosis or hypoglycemic reactions over the past twelve months. The Veteran was provided a VA examination in November 2020. The VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The Veteran reported that his diabetes treatment included restricted diet, oral hypoglycemic agents, and insulin injections more than once per day. The VA examiner noted that the Veteran visits his diabetic care provider for episodes of ketoacidosis and hypoglycemia less than two times per months. The Veteran had zero hospitalizations in the past twelve months related to episodes of ketoacidosis or hypoglycemia. Accordingly, the relevant medical evidence of record reflects that the Veteran's diabetes mellitus, type II, was managed with diet, insulin, and regulation of activities. Such manifestations meet the criteria for a 40 percent rating under Diagnostic Code 7913. In this case, the medical evidence of record does not reflect episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider such that a rating in excess of 40 percent is warranted. In making its determinations in this case, the Board has carefully considered the Veteran's contentions with respect to the nature and severity of his service-connected diabetes mellitus at issue, and notes that his lay testimony is competent to describe symptoms, capable of lay observation, associated with this disability. The Veteran's history and symptom reports have been considered, including as presented in the medical evidence discussed above, and are noted to be contemplated by the criteria for the disability rating for which the Veteran has been found entitled by the Board. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disability at issue. As such, while the Board accepts the Veteran's statements with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected condition at issue. The Board therefore finds that the criteria for a rating in excess of 40 percent for the Veteran's service-connected type II diabetes mellitus to include erectile dysfunction have not been met at any time during the rating period. Accordingly, there is no basis for staged ratings of the Veteran's type II diabetes mellitus to include erectile dysfunction pursuant to Hart, 21 Vet. App. at 519, and a higher rating must be denied. As the evidence persuasively weighs against the Veteran's claim, the benefit-of-the-doubt doctrine is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990); Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND 1. Entitlement to service connection for sleep apnea is remanded. The Veteran contends that he has sleep apnea that is directly related to his active service or secondary to his service-connected disabilities, to include medication he takes for his service-connected disabilities. Pursuant to the September 2019 Board remand, the Veteran was provided a VA examination related to his sleep apnea in November 2020. VA has a duty to ensure that any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board's evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Here, the Board finds the November 2020 VA opinion is inadequate for decision making purposes. The VA examiner noted the Veteran's current diagnosis of obstructive sleep apnea and opined that the disability is less likely than not proximately due to or the result of his service-connected disabilities. As rationale, the VA examiner explained that sleep apnea occurs when the muscles in the back of the throat relax; when the muscles relax, the airway narrows or closes. As such, the VA examiner concluded that a nexus cannot be established, to include from the Veteran's service-connected disabilities. However, the VA examiner did not address whether medications the Veteran takes related to his service-connected disabilities caused his sleep apnea, as directed by the September 2019 Board remand. Additionally, the VA examiner did not provide an opinion as to whether the Veteran's sleep apnea is aggravated by his service-connected disabilities. In that regard, the Board notes that an opinion to the effect that one disability "is not caused by or a result of" another disability does not answer the question of aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). Accordingly, the November 2020 VA examination is inadequate for decision-making purposes and does not substantially comply with the September 2019 Board remand. Barr, 21 Vet. App. at 312; see also Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Board remand). 2. Entitlement to service connection for arthritis is remanded. The Veteran contends that he has arthritis of the cervical spine, hands, and shoulders related to his active service or secondary to a service-connected disability. Specifically, the Veteran contends that his current arthritis is related to parachute jumps and/or his presumed exposure to herbicide agents during his active service. In the alternative the Veteran contends that his current arthritis is secondary to his service-connected diabetes mellitus, type II. The issue of entitlement to service connection for arthritis was remanded in September 2019. The VA examiner was directed to provide an opinion as to whether the Veteran's current arthritis was caused by in-service parachute jumps or his presumed exposure to herbicide agents. The VA examiner was further directed to opine whether the Veteran's arthritis is secondary to his service-connected diabetes mellitus, type II. Pursuant to the September 2019 Board remand, the Veteran was provided VA examinations related to his claimed arthritis in November 2020. The VA examiner opined that the Veteran's hand arthritis is less likely than not incurred in or caused by the claimed in-service injury event, or illness. As rationale, the VA examiner explained that the records are silent for a hand injury during active service. The VA examiner further explained that there is no medical literature to support a causal relationship between the current bilateral hand condition and Agent Orange. In a separate opinion, the VA examiner opined that the Veteran's current hand arthritis is less likely than not proximately due to or the result of his service-connected diabetes mellitus, type II. As rationale, the VA examiner explained that there is no medical literature to support a causal relationship between the current bilateral hand condition and service-connected diabetes. The VA examiner did not provide an opinion as to whether the Veteran's arthritis is aggravated by his service-connected diabetes mellitus, type II. As to the Veteran's cervical spine arthritis, the VA examiner explained that the records are silent related to his injury during the Veteran's active service even though the record reflects he was a paratrooper. In a separate opinion, the VA examiner opined that the Veteran's current cervical spine disability is less likely than not proximately due to or the result of his service-connected diabetes mellitus, type II. As rationale, the VA examiner explained that there is no medical literature to support a causal relationship between the current cervical spine disability and his service-connected diabetes. The VA examiner did not provide an opinion as to whether the Veteran's arthritis is aggravated by his service-connected diabetes mellitus, type II. As to the Veteran's shoulder disability, the VA examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service event, or illness. As rationale, the VA examiner explained that the Veteran's records are silent for a disability during his active service. The VA examiner further explained that there is no medical literature to support a causal relationship between the current shoulder disability and Agent Orange. In a separate opinion, the VA examiner opined that the Veteran's current shoulder arthritis is less likely than not proximately due to or the result of his service-connected diabetes mellitus, type II. As rationale, the VA examiner explained that there is no medical literature to support a causal relationship between the current bilateral shoulder arthritis and his service-connected diabetes. The VA examiner did not provide an opinion as to whether the Veteran's arthritis is aggravated by his service-connected diabetes mellitus, type II. Here, the Board finds the November 2020 VA opinions are inadequate for decision making purposes. The VA examiner continually noted that there was no evidence of arthritis during the Veteran's active service. However, a review of the Veteran's service treatment records reveal that the Veteran complained of swollen and painful joints at his March 1971 exit examination. Although that examination does not note arthritis specifically, it does indicate that the Veteran had in-service joint complaints, to include at the time of his separation from active service. Additionally, the VA examiner did not provide an adequate opinion as to whether the Veteran's current arthritis is related to parachute jumps and/or his presumed herbicide agent exposure. Furthermore, the VA examiner did not provide an opinion as to whether the Veteran's arthritis is aggravated by his service-connected diabetes mellitus, type II. In that regard, the Board notes that an opinion to the effect that one disability "is not caused by or a result of" another disability does not answer the question of aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). Accordingly, the November 2020 VA examinations are inadequate for decision-making purposes and do not substantially comply with the September 2019 Board remand. Barr, 21 Vet. App. at 312; see also Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Board remand). 3. Entitlement to service connection for a low back disability is remanded. The Veteran contends that he has a low back disability that is directly related to his active service. Specifically, the Veteran contends that his low back disability is related to parachute jumps he made during active or to his presumed exposure to herbicide agents. The issue of entitlement to service connection for a low back disability was remanded in September 2019. The VA examiner was directed to provide an opinion as to whether the Veteran's current low back disability was caused by in-service parachute jumps or his presumed exposure to herbicide agents. Pursuant to the September 2019 Board remand, the Veteran was provided a VA examination in November 2020. The VA examiner opined that the Veteran's current low back disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As rationale, the VA examiner explained that the Veteran's medical records are silent relating to a low back disability and upon his exit examination there was no complaints or history of a low back disability. The VA examiner further explained that it is known that trauma to lumbar vertebrae can increase the aging and degenerative process of the joints, but there is not enough evidence found in records to suggest a significant low back injury during service, which led to a chronic low back condition. However, a review of the Veteran's service treatment record reflect that the Veteran complained of back trouble at his March 1971 exit examination. Additionally, the VA examiner did not address whether the Veteran's current low back disability is due to parachute jumps and/or his presumed exposure to herbicide agents during his active service. Accordingly, the November 2020 VA examination is inadequate for decision-making purposes and does not substantially comply with the September 2019 Board remand. Barr, 21 Vet. App. at 312; see also Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Board remand). 4. Entitlement to service connection for bilateral plantar fasciitis is remanded. The Veteran contends that he has bilateral plantar fasciitis that is directly related to his active service. Specifically, the Veteran contends that his bilateral plantar fasciitis is related to parachute jumps he made during active or to his presumed exposure to herbicide agents. The issue of entitlement to service connection for bilateral plantar fasciitis was remanded in September 2019. The VA examiner was directed to provide an opinion as to whether the Veteran's current bilateral plantar fasciitis was caused by in-service parachute jumps or his presumed exposure to herbicide agents. Pursuant to the September 2019 Board remand, the Veteran was provided a VA examination in November 2020. The VA examiner opined that the Veteran's current bilateral plantar fasciitis was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As rationale, the VA examiner explained that the Veteran's medical records are silent relating to an in-service foot disability and upon his exit examination there was no complaints or history of a foot disability. The VA examiner further explained that there is no medical literature to support a causal relationship between the current bilateral foot condition and Agent Orange. The Board notes that the VA examiner did not address whether the Veteran's current bilateral plantar fasciitis is due to parachute jumps as directed by the September 2021 Board remand. Additionally, the VA examiner based the opinion that the Veteran's current bilateral plantar fasciitis is not related to herbicide agent exposure based on a lack of medical literature. Reliance on the absence of medical literature supporting nexus without discussing the specific facts of the case, including any risk factors that may contribute to the particular disability at issue, renders an opinion inadequate. Bailey v. O'Rourke, 30 Vet. App. 54, 60 (2018) Accordingly, the November 2020 VA examination is inadequate for decision-making purposes and does not substantially comply with the September 2019 Board remand. Barr, 21 Vet. App. at 312; see also Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Board remand). 5. Entitlement to increased disability ratings for bilateral upper extremity and bilateral lower extremity peripheral neuropathy is remanded. The Board finds that further development is necessary before a decision on the merits may be made regarding the issues of entitlement to higher disability ratings for bilateral upper extremity and bilateral lower extremity peripheral neuropathy. The Veteran was last provided a VA examination relating to his peripheral neuropathy in April 2015, nearly seven years ago. In a November 2021 statement, it was reported that the Veteran could not open and close his hands or walk due to his bilateral upper extremity and bilateral lower extremity peripheral neuropathy. In light of the assertions, a new VA examination is required so that the current nature and severity of the Veteran's service-connected disabilities may be determined. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; see also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the veteran with a thorough and contemporaneous medical examination); Weggenmann v. Brown, 5 Vet. App. 281 (1993) (VA has a duty to provide an examination when there is evidence that the disability has worsened since the previous examination). 6. Entitlement to a TDIU from October 23, 2008, is remanded. The claim for a TDIU is inextricably intertwined with the Veteran's claims for entitlement to service connection for sleep apnea, a low back disability, and arthritis and the issues of entitlement to increased ratings for bilateral upper extremity and bilateral lower extremity peripheral neuropathy. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (the prohibition against the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). 7. Entitlement to an SMC based on the need for regular aid and attendance is remanded. As noted above, in a November 2021 statement, the Veteran's daughter reported that the "list of assisting [the Veteran] with daily functions is extensive." However, the medical evidence of record is not clear as to whether the Veteran's service-connected disabilities alone result in him being so helpless as to be in need of regular aid and attendance. Therefore, the Veteran should be provided an opportunity to report for a VA examination to ascertain whether he is so helpless as to be in need of regular aid and attendance of another person due to his service-connected disabilities. The matters are REMANDED for the following action: 1. Forward the record and a copy of this remand to the examiner who conducted the November 2020 VA examination, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. Following review of the record, the examiner should express an opinion as to: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's sleep apnea is related to the Veteran's active service, to include his presumed exposure to herbicide agents. The examiner must note that, although sleep apnea is not among the conditions subject to presumptive service connection as a disease associated with exposure to herbicide agents under 38 C.F.R. § 3.309(e), the Veteran is not precluded from establishing service connection for sleep apnea with proof of direct causation. See Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In discussing the Veteran's exposure to herbicide agents, the examiner must not rely solely on the absence of medical literature supporting a nexus, but rather must also discuss the specific facts of the case, including any risk factors that may contribute to the particular disability at issue. (b.) If not, whether it is at least as likely as not (50 percent or greater probability) that the Veteran's sleep apnea is proximately due to or the result of his service-connected disabilities, specifically to include medication he takes related to his service-connected disabilities. Rationale must be provided for the opinion proffered. In rendering the requested rationale, the examiner must note that it is not required that the sleep apnea is shown to be "predominantly" due to or result of his service-connected disabilities, but rather, whether there is any contributing degree of etiological relationship to his service-connected disabilities. (c.) If not, whether it is at least as likely as not (50 percent or greater probability) that the Veteran's sleep apnea is aggravated beyond natural progression by his service-connected disabilities, specifically to include medication he takes related to his service-connected disabilities. Rationale must be provided for the opinion proffered. In rendering the requested rationale, the examiner must note that it is not required that the sleep apnea is shown to be aggravated beyond natural progression "predominantly" by his service-connected disabilities, but rather, whether there is any contributing degree of aggravation beyond natural progression by the service-connected disabilities. 2. Forward the record and a copy of this remand to the examiner who conducted the November 2020 VA examinations, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. Following review of the record, the examiner should express an opinion as to: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's arthritis is related to the Veteran's active service, to include parachute jumps and his presumed exposure to herbicide agents. The examiner must note that, although arthritis is not among the conditions subject to presumptive service connection as a disease associated with exposure to herbicide agents under 38 C.F.R. § 3.309(e), the Veteran is not precluded from establishing service connection for arthritis with proof of direct causation. See Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In discussing the Veteran's exposure to herbicide agents, the examiner must not rely solely on the absence of medical literature supporting a nexus, but rather must also discuss the specific facts of the case, including any risk factors that may contribute to the particular disability at issue. (b.) If not, whether it is at least as likely as not (50 percent or greater probability) that the Veteran's arthritis is proximately due to or the result of his service-connected disabilities, specifically to include his service-connected diabetes mellitus, type II. Rationale must be provided for the opinion proffered. In rendering the requested rationale, the examiner must note that it is not required that the arthritis is shown to be "predominantly" due to or result of his service-connected diabetes mellitus, type II, but rather, whether there is any contributing degree of etiological relationship to his service-connected diabetes mellitus, type II. (c.) If not, whether it is at least as likely as not (50 percent or greater probability) that the Veteran's arthritis is aggravated beyond natural progression by his service-connected disabilities, specifically to include his service-connected diabetes mellitus, type II. Rationale must be provided for the opinion proffered. In rendering the requested rationale, the examiner must note that it is not required that the arthritis is shown to be aggravated beyond natural progression "predominantly" by his service-connected diabetes mellitus, type II, but rather, whether there is any contributing degree of aggravation beyond natural progression by the service-connected diabetes mellitus, type II. 3. Forward the record and a copy of this remand to the examiner who conducted the November 2020 VA examination, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. Following review of the record, the examiner should express an opinion as to: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's low back disability and/or bilateral plantar fasciitis are related to the Veteran's active service, to include parachute jumps and his presumed exposure to herbicide agents. The examiner must note that, although degenerative disc disease and plantar fasciitis are not among the conditions subject to presumptive service connection as a disease associated with exposure to herbicide agents under 38 C.F.R. § 3.309(e), the Veteran is not precluded from establishing service connection for degenerative disc disease and/or plantar fasciitis with proof of direct causation. See Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In discussing the Veteran's exposure to herbicide agents, the examiner must not rely solely on the absence of medical literature supporting a nexus, but rather must also discuss the specific facts of the case, including any risk factors that may contribute to the particular disability at issue. 4. Schedule the Veteran for a VA examination to determine the current nature and severity of his service-connected bilateral upper extremity and bilateral lower extremity peripheral neuropathy. The record and a copy of this remand must be made available to and reviewed by the examiner. The examination must include all physical and diagnostic testing deemed necessary by the examiner in conjunction with this request. The examiner should report all manifestations and functional impairment related to the Veteran's service-connected bilateral upper extremity and bilateral lower extremity peripheral neuropathy. 5. Schedule the Veteran for a VA aid and attendance examination to address whether the following are present as a result of his service-connected disabilities: (1) inability to dress or undress himself or to keep himself ordinarily clean and presentable; (2) frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this does not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacking at the back, etc.); (3) inability to attend to the wants of nature; (4) inability to feed himself through loss of coordination of the upper extremities or through extreme weakness; or (5) incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his daily environment. The examiner should limit his or her consideration to the effects of the Veteran's service-connected disabilities and should disregard the effects of the Veteran's nonservice-connected disabilities. 6. After completion of the above, review the expanded record, including the evidence entered since the most recent supplemental statement of the case, and determine whether entitlement to service connection for sleep apnea, arthritis, a low back disability, and bilateral plantar fasciitis; entitlement to increased ratings for bilateral upper extremity and bilateral lower extremity peripheral neuropathy; entitlement to a TDIU; and/or entitlement to a SMC may be granted. If any benefit sought remains denied, furnish the Veteran and his representative with a supplemental statement of the case. The appropriate period should be allowed for response before the appeal is returned to the Board. T. J. ANTHONY Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. G. LeMoine, 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.