Citation Nr: 22016897 Decision Date: 03/23/22 Archive Date: 03/23/22 DOCKET NO. 19-15 734A DATE: March 23, 2022 REMANDED Entitlement to service connection for diabetes, to include as due to posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for a right big toe amputation, to include as secondary to diabetes, is remanded. Entitlement to service connection for a right hand condition, to include as secondary to diabetes, is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to diabetes, is remanded. Entitlement to service connection for a voiding dysfunction, to include as secondary to diabetes, is remanded. Entitlement to a rating greater than 20 percent for a back disability is remanded. Entitlement to a rating greater than 50 percent for PTSD is remanded. Entitlement to a compensable rating for residuals of a fracture of the fifth metacarpal bone of the left hand is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1991 to November 1996. In July 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing is associated with the record. 1. Entitlement to service connection for diabetes, to include as secondary to PTSD, is remanded. The Board is unable to make an informed decision on the issue of service connection for diabetes because additional development is necessary. During the Veteran's July 2021 Board hearing, the Veteran raised the theory that his service-connected PTSD and back disabilities caused his obesity, an intermediary to his diabetes condition. Obesity itself is not a disability and thus, cannot be the subject of service connection. VAOPGCPREC No. 1-2017 (Jan. 6, 2017). However, obesity may act as an "intermediate step" between a service-connected disability and a current disability that may be service-connected on a secondary basis under 38 C.F.R. § 3.310(a). The claim is remanded to obtain a medical opinion that considers that theory. 2. Entitlement to service connection for ED, to include as secondary to diabetes, is remanded. The Board is unable to make an informed decision on the issue of service connection for erectile dysfunction because additional development is necessary. In addition to the Veteran's theory of entitlement that his ED was caused by his diabetes, the Veteran further contends that his ED was caused or aggravated by his PTSD. No medical opinion was obtained to assist in a decision on this new theory of entitlement. Thus, a VA medical examination is warranted. 3. Entitlement to service connection for a right big toe amputation, to include as secondary to diabetes, is remanded. 4. Entitlement to service connection for a right hand condition, to include as secondary to diabetes, is remanded. 5. Entitlement to service connection for a voiding dysfunction, to include as secondary to diabetes, is remanded. The service connection claims for a right big toe amputation, right hand condition, and voiding dysfunction are inextricably intertwined with the service connection claim for diabetes and will be deferred until the issue of service connection for diabetes is decided. 6. Entitlement to a rating greater than 20 percent for a back disability is remanded. 7. Entitlement to a rating greater than 50 percent for PTSD is remanded. The Veteran testified at his July 2021 Board hearing that his PTSD and back disabilities have worsened since his November 2018 VA examinations. Due to the passage of time and the Veteran's testimony of worsening symptoms, new VA examinations are warranted. 8. Entitlement to a compensable rating for residuals of a fracture of the fifth metacarpal bone of the left hand is remanded. The Board is unable to make an informed decision on the issue of a compensable rating for the Veteran's left hand disability because additional development is necessary. During his July 2021 Board hearing, the Veteran described having upper extremity neurological symptoms that may be causally related to diabetic neuropathy. A VA examination is necessary to determine if the Veteran's left hand disability has worsened or whether he has a separate neurological diagnosis. The matters are REMANDED for the following action: 1. Obtain a medical opinion from an appropriate clinician on the likely etiology of the Veteran's diabetes. Copies of all pertinent records must be made available to the examiner. If the examiner determines that an opinion cannot be provided without an examination, one should be scheduled. The examiner is asked to answer the following questions: (a) Is it at least as likely as not (50 percent probability) that the Veteran's diabetes was incurred in or related to his service? (b) If the answer to (a) is no, is it at least as likely as not that the diabetes was (i) caused by the Veteran's service-connected PTSD or back disabilities or (ii) aggravated by (defined as any increase in disability) the service-connected PTSD or back disabilities? (c) If the answer to (a) and (b) are no, the examiner must answer the following: (i) whether the service-connected PTSD or back disability caused or aggravated the Veteran's obesity; (ii) if so, whether the obesity as a result of the service-connected PTSD or back disability was a substantial factor in causing or aggravating the diabetes, and; (iii) whether the diabetes would not have occurred but for the obesity caused by his service-connected PTSD or back disability? A complete rationale must be provided for all opinions, citing to supporting factual data and medical literature, as appropriate. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training) and note what, if any, additional evidence would permit such an opinion to be made. 2. Schedule the Veteran for a VA examination (or tele-health interview, review of the record, etc., if an in-person examination is not feasible) with an appropriate VA examiner, to determine the likely etiology of his ED. Copies of all pertinent records must be made available to the examiner. The examiner is asked to answer the following questions: (a) Is it at least as likely as not (50 percent probability) that any currently diagnosed ED has been (i) caused or (ii) aggravated by the service-connected PTSD? Aggravation here is defined as any increase in disability. In answering this, the examiner must review and discuss the articles submitted by the Veteran in July 2021 titled (i) Sexual Dysfunction in Combat Veterans with Post-Traumatic Stress Disorder, and; (ii) Diabetes and Erectile Dysfunction A complete rationale must be provided for all opinions, citing to supporting factual data and medical literature, as appropriate. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training) and note what, if any, additional evidence would permit such an opinion to be made. 3. Schedule the Veteran for a VA examination (or tele-health interview, review of the record, etc., if an in-person examination is not feasible) with an appropriate VA examiner, to determine the current nature and likely etiology of the right big toe amputation, right hand, and voiding dysfunction conditions. Copies of all pertinent records must be made available to the examiner. Thr examiner is asked to answer the following: (a Identify all currently diagnosed disabilities affecting the right big toe, right hand and voiding dysfunction. (b Is it at least as likely as not (probability of at least 50 percent) that any diagnosed right big toe, right hand or voiding dysfunction disability was (i) caused by or (ii) aggravated the Veteran's diabetes? Aggravation here is defined as any increase in disability. A complete rationale must be provided for all opinions, citing to supporting factual data and medical literature, as appropriate. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training) and note what, if any, additional evidence would permit such an opinion to be made. 4. Schedule the Veteran for the appropriate VA examination to assess the severity of his service-connected PTSD and back disabilities. Copies of all pertinent medical records should be made available to the examiner for review. All necessary diagnostic testing should be performed using the appropriate DBQ if available. 5. Schedule the Veteran for the appropriate VA examination to assess the severity of his service-connected left hand disability. Copies of all pertinent medical records should be made available to the examiner for review. All necessary diagnostic testing should be performed using the appropriate DBQ if available. The examiner is asked to identify all manifestations of the left hand, to include whether there are any neurological condition. The examiner must consider the Veteran's complaints and whether any identified neurological symptoms are caused by the Veteran's service-connected residuals of a fracture of the fifth metacarpal bone or other etiological cause (i.e., diabetic neuropathy). 6. Confirm that the VA medical opinions provided comports with this remand, specifically that the standard for the secondary aggravation opinions is any increase in disability, not the standard of beyond the natural progression as noted on the examination form itself. If not, get addendum opinions. M.E. Larkin Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. G. Perkins, 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.