HERNIA VENTRAL POSTOPERATIVE

Summary

The veteran served from 1987 to 2007, with service in Southwest Asia involving exposure to burn pits, toxins, fuel, chemicals, solvents, and minimal asbestos. The veteran appealed the denial of service connection for an umbilical hernia and sought an increased rating for tinea pedis. The Board denied service connection for the umbilical hernia, finding that the veteran's claim of pre-existing condition was not supported by service treatment records, and the VA examiner opined it was not related to service or TERAs. The Board also denied a compensable evaluation for tinea pedis, concluding that the condition, even when active, affected less than 5% of the body and did not meet the criteria for a compensable rating under either pre- or post-August 13, 2018 regulations, as treatments were topical and intermittent. The case was remanded for further development regarding diabetes mellitus type II (DMII) and peripheral neuropathy, as the VA opinions were inadequate regarding causation, aggravation, and the role of obesity and TERAs. The Board noted procedural issues with the AOJ's handling of the DMII claim under the incorrect appeals system.

Rationale

No hernia noted on enlistment examination; Lay reporting of childhood hernia insufficient to overcome presumption of soundness; VA treatment records show hernia diagnosed over four years after service; VA examiner opined hernia not service-related, due to increased intra-abdominal pressure

Full Decision Text

Citation Nr: 26004651
Decision Date: 04/16/26	Archive Date: 04/16/26

DOCKET NO. 16-44 215A
DATE: April 16, 2026

ORDER

Service connection for an umbilical hernia is denied.

A compensable evaluation for tinea pedis is denied. 

REMANDED

Entitlement to service connection for diabetes mellitus, type II (DMII) is remanded.

Entitlement to service connection for right lower extremity peripheral neuropathy is remanded.

Entitlement to service connection for left lower extremity peripheral neuropathy is remanded.

FINDINGS OF FACT

1. The Veteran's umbilical hernia onset four years after his separation from service and is not otherwise related to his service. 

2. The Veteran's tinea pedis covers less than 5 percent of his total and exposed body areas and has not required systemic therapy.  

CONCLUSIONS OF LAW

1. The criteria for service connection for an umbilical hernia are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for a compensable evaluation for tinea pedis are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.118, Diagnostic Code (DC) 7813. 

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from 1987 to 2007. 

This appeal to the Board of Veterans' Appeals (Board) is from December 2014 and June 2015 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO), which is the Agency of Original Jurisdiction (AOJ).

This appeal was most recently before the Board in October 2024, at which time it was remanded for further development. The appeal now returns to the Board for adjudication. 

Service Connection for Umbilical Hernia

The Veteran asserts that he has an umbilical hernia that preexisted his service and was aggravated beyond the natural progression of the disorder by his service.

Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111. This presumption attaches only where there has been an induction examination in which the later-complained-of disability was not noted. To be "noted" within the meaning of the presumption of soundness statute, the condition must be recorded in the entrance examination report. 38 C.F.R. § 3.304(b); see also 38 U.S.C. § 1111; Crowe v. Brown, 7 Vet. App. 238, 245 (1994).

The Veteran indicates that a service treatment record shows that he had a hernia as a child and as such, his umbilical hernia preexisted his service. A review of the record shows that the notation of a hernia was made by the Veteran on a Report of Medical History that he completed for enlistment. There is no hernia or history of hernia noted on the enlistment examination. 

The mere reporting of a lay medical history on enlistment by the Veteran is not enough to overcome the presumption of soundness. See Gahman v. West, 13 Vet. App. 148, 150 (1999) (recorded history provided by a lay witness does not constitute competent medical evidence sufficient to overcome the presumption of soundness, even when such is recorded by medical examiners); Crowe v. Brown, 7 Vet. App. 238 (1994) (supporting medical evidence is needed to establish the presence of a preexisting condition).

As such, the Veteran is considered to have been sound upon entrance to service in regard to his umbilical hernia. Thus, the AOJ developed this claim as directly due to the Veteran's toxic exposure risk activities (TERAs) during service. 

Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal
 medical evidence is needed to establish the presence of a preexisting condition).

As such, the Veteran is considered to have been sound upon entrance to service in regard to his umbilical hernia. Thus, the AOJ developed this claim as directly due to the Veteran's toxic exposure risk activities (TERAs) during service. 

Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence must show: (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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

The record shows that the Veteran had service in Southwest Asia and was exposed to burn pits and other toxins, to include fine particulate matter, as well as exposure to fuel, exhaust, various chemicals/solvents, and minimal asbestos. 

?

VA treatment records from August 2007 through August 2011 show that the Veteran had no hernia. A September 2011 VA treatment record shows that the Veteran was diagnosed with an umbilical hernia, and he stated that the pain onset four to six weeks prior. The Veteran stated that he had an appendectomy in August 2011 and he thought that might be related to his umbilical hernia. 

Pursuant to the October 2024 remand, the Veteran underwent a VA hernia examination in February 2025. The examiner confirmed a diagnosis of an umbilical hernia with surgical repair in 2013. The Veteran indicated that his hernia originally onset in 2011, four years after his separation from service. The examiner opined that the Veteran's umbilical hernia is not due to service, including his TERAs, rather umbilical hernias are usually due to increased intrabdominal pressure from things such as obesity, chronic cough, constipation, heavy lifting, and straining. The examiner further explained that there is no correlation between umbilical hernias and blunt force trauma, repetitive trauma, or penetrative trauma. 

Ultimately, the Board finds that the Veteran's umbilical hernia is not due to his service, including his TERAs. The medical evidence of record, including extensive VA treatment records, shows that the Veteran's umbilical hernia was diagnosed in September 2011, which is over four years after his separation from service. Per the Veteran's own statements, pain onset around August 2011 after his appendectomy. When the Veteran presented for treatment in September 2011, he did not indicate that he had any history of hernias, including in childhood. The evidence of record simply does not support that the Veteran's umbilical hernia was caused by his service. 

In conclusion, the Board finds that the evidence of record persuasively weighs against the Veteran's claim for service connection for an umbilical hernia. As the evidence of record persuasively weighs against the claim, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).  

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Increased Evaluation for Tinea Pedis

The Veteran asserts that his tinea pedis (athlete's foot) is more severe than contemplated by his currently assigned noncompensable evaluation. 

Disability evaluations are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.
., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10.

In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two evaluations, the higher evaluation will be assigned; otherwise, the lower evaluation is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under various diagnoses, and the evaluation of the same manifestation under different diagnoses, are to be avoided. 38 C.F.R. § 4.14.

Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119 (1999). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007).

The appeal period before the Board for tinea pedis begins on February 5, 2014, the date VA received the Veteran's claim for increased evaluation for tinea pedis, plus the one-year look back period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010).

VA amended the criteria for rating skin disabilities effective August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the AOJ on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal.

Prior to August 13, 2018, DC 7813 instructed to rate as disfigurement of the face, or neck (DC 7800) or scars (DCs 7801, 7802, 7803, 7804, or 7805), or dermatitis (7806) depending on the predominant disability. 38 C.F.R. § 4.118, DC 7813. 

A September 2014 Disability Benefits Questionnaire (DBQ) submitted by the Veteran shows that the predominant disability is dermatitis. There was no finding of a scar or disfigurement of the face or neck. A June 2015 VA skin diseases examination found the same. The predominant disability is dermatitis. 

Prior to August 13
, DC 7813 instructed to rate as disfigurement of the face, or neck (DC 7800) or scars (DCs 7801, 7802, 7803, 7804, or 7805), or dermatitis (7806) depending on the predominant disability. 38 C.F.R. § 4.118, DC 7813. 

A September 2014 Disability Benefits Questionnaire (DBQ) submitted by the Veteran shows that the predominant disability is dermatitis. There was no finding of a scar or disfigurement of the face or neck. A June 2015 VA skin diseases examination found the same. The predominant disability is dermatitis. 

Prior to August 13, 2018, under DC 7806, a noncompensable evaluation is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12 months. A 10 percent evaluation is assigned for at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent evaluation is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent evaluation is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, DC 7806.  

For claims filed prior to August 13, 2018, the Court held that a systematic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran's skin condition; and (2) whether the given treatment is "like" a corticosteroid or other immunosuppressive drug." Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Id.  

Effective August 13, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a).

Additionally, effective August 13, 2018, a new General Rating Formula for the Skin applies to DCs 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824. See 38 C.F.R. § 4.118. Under this formula, a noncompensable evaluation is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent evaluation is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12- month period. A 30 percent evaluation is assigned at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more,
 including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12- month period. A 30 percent evaluation is assigned at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent evaluation is assigned for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, General Rating for the Skin for DCs 7806, 7809, 7813-7816, 7820-7822, and 7824.

The September 2014 DBQ shows that the Veteran was prescribed a topical corticosteroid that day, and that he uses an over-the-counter body lotion. The Veteran reported no other treatment for his tinea pedis in the year preceding the examination. The doctor observed that the Veteran's dermatitis and eczema covered less than 5 percent of the Veteran's exposed body area. It appears that the Veteran presented to this doctor to establish care and have the DBQ completed, as the doctor indicated that it was the Veteran's first visit and the known medical history concerning tinea pedis was limited. 

A June 2015 VA skin diseases examination shows that the Veteran complained of dry scale, itching, and occasional pain between his toes. The Veteran reported that he had used an "unknown topical cream" for less than six weeks in the year preceding the examination. There was no history of debilitating or non-debilitating episodes of urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis. Physical examination showed that the Veteran's tinea pedis affects none of his visible body area, and less than five percent of his total body area. The examiner indicated that the Veteran had "a minute amount of scale to the interdigital areas" and that the itchiness poses some functional impact to the Veteran, however he was employed.

A June 2022 VA treatment record shows that the Veteran stated that he had a rash on his stomach, buttock, and thigh area. The Veteran was prescribed a topical cream. 

In February 2025 the Veteran underwent a VA skin diseases examination. At the time of the examination the Veteran had no current tinea pedis or other rash, and he reported that he has "intermittent rash of feet." Treatment over the year preceding the examination included a topical corticosteroid or other immunosuppressive, for six weeks or more but not constant. The Veteran reported no treatments or procedures other than systemic or topical medications in the past year. Because the Veteran had no active tinea pedis or other rash at the time of the examination, none of his total or exposed body area was affected. 

The February 2025 VA examiner also identified the different medications the Veteran had been prescribed for his tinea pedis throughout the appeal period. Specifically, in 2017 the Veteran was on a 21-day course of Terbinafine which is an oral antifungal. The Veteran used Triamcinolone cream in the 12 months preceding the examination. The Veteran's prior medications include Ketoconazole for a 14-day course in 2017, Clobetasol for a 14-day course in 2017, Triamcinolone from 2013 to 2017 and currently. The Veteran used Nystatin/Triamcinolone from 2013 to 2015 and again in 2022. Finally, the examiner indicated that there is mention of a biopsy which showed hives but no actual pathology report was available. There is no evidence of scarring. The examiner stated
 on a 21-day course of Terbinafine which is an oral antifungal. The Veteran used Triamcinolone cream in the 12 months preceding the examination. The Veteran's prior medications include Ketoconazole for a 14-day course in 2017, Clobetasol for a 14-day course in 2017, Triamcinolone from 2013 to 2017 and currently. The Veteran used Nystatin/Triamcinolone from 2013 to 2015 and again in 2022. Finally, the examiner indicated that there is mention of a biopsy which showed hives but no actual pathology report was available. There is no evidence of scarring. The examiner stated that these medications largely were topical creams that the Veteran used intermittently as needed, and none of these medications are considered systemic therapy as there is very little absorption of the substances. 

As such, the Board finds that the Veteran's topical treatments did not, at any point during the period on appeal, affect the body as a whole. Further, the medications are not like a corticosteroid or other immunosuppressive drug, as the absorption through the skin from topical treatment is minimal. 

The Board finds that the evidence of record persuasively weighs against the assignment of a compensable evaluation under the pre-August 13, 2018, regulations because the Veteran's tinea pedis does not more nearly approximate at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period.  

Rather, the evidence shows that when the Veteran's tinea pedis is active, it covers less than 5 percent of his total body area, mainly the space in between his toes. Further, none of the Veteran's medications are considered systemic, regardless of the length of use.  

The Board finds that the evidence of record persuasively weighs against the assignment of a compensable evaluation under the August 13, 2018, regulations because the Veteran's tinea pedis does not more nearly approximate (1) characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or (2) at least 5 percent, but less than 20 percent, of exposed areas affected; or (3) intermittent systemic therapy required for a total duration of less than 6 weeks over the past 12- month period.  

The Board is mindful of the June 2022 VA treatment record showing that the Veteran stated that he had a rash on his stomach, buttock, and thigh area. However, this treatment record does not show that the Veteran's tinea pedis (athlete's foot) was related to this rash, or how much of the body area was affected by the rash. The Board notes that while a rash may be present on multiple body parts, that alone does not necessarily mean that the rash was widespread on those parts of the body or covering more than 5 percent of body area, total or exposed. 

The Veteran believes that his tinea pedis has been more severe than the assigned disability evaluation reflects. Moreover, the Veteran is competent to report observable symptoms, to include where a rash is present, and these reports are credible. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, medical treatment records do not show that the Veteran's tinea pedis more nearly approximates the criteria in the next higher evaluation. Rather the majority of the evidence shows that the Veteran's tinea pedis is limited to his feet, specifically the area between his toes, and thus, is not closer to affecting 5 to 20 percent of the Veteran's body area. 

The Board has considered whether any other DCs related to disabilities of the skin would provide for a higher disability evaluation. However, tinea pedis is directly contemplated by the assigned DC, and as such, other DCs are not for application. See generally 38 C.F.R. § 4.118, DC 7813. 

In conclusion, the Board finds that the evidence of record persuasively weighs against the Veteran's claim for a compensable evaluation for tinea pedis. As the evidence of record persuasively weighs against the claim, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102; Lynch, supra. 

REASONS FOR REMAND

The October 2024 remand directed that, concerning DMII, a VA examiner
 is directly contemplated by the assigned DC, and as such, other DCs are not for application. See generally 38 C.F.R. § 4.118, DC 7813. 

In conclusion, the Board finds that the evidence of record persuasively weighs against the Veteran's claim for a compensable evaluation for tinea pedis. As the evidence of record persuasively weighs against the claim, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102; Lynch, supra. 

REASONS FOR REMAND

The October 2024 remand directed that, concerning DMII, a VA examiner must opine as to whether it is directly due to service, including TERAs or secondary to his service-connected sleep apnea, left knee disorder, and spine disorder. The remand also directed that if not granted in full, the AOJ must issue a supplemental statement of the case (SSOC) and return the appeal to the Board. 

Concerning secondary service connection, a February 2025 VA examiner opined that the Veteran's DMII is not aggravated by his sleep apnea. The examiner did not provide any opinion as to the causation prong of secondary service connection. Discussion of both causation and aggravation is required for an adequate secondary service connection opinion. See Atencio v. O'Rourke, 30 Vet. App. 74, 90 (2018) (holding that, in claims involving service connection on a secondary basis, VA medical opinions must provide separate findings and rationales regarding both causation and aggravation); El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (a medical opinion is inadequate when it fails to adequately address the question of aggravation). 

Concerning the Veteran's TERAs, a June 2025 VA examiner opined that the Veteran's DMII is not due to his TERAs, however, the examiner provided no explanation to support this opinion. The examiner's opinion in this regard is conclusory. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Thus, the TERA opinion rendered is inadequate. 

The AOJ also initiated development of the claim for service connection for DMII with obesity as an intermediate step. A June 2025 addendum opinion shows that the examiner was asked to opine as to whether the Veteran's sleep apnea, left knee disorder, and/or his spine disorder caused his obesity, whether obesity was a substantial factor in causing DMII, and whether DMII would not have occurred but for his obesity. The examiner stated that the Veteran's knee and spine disorders "could cause" less activity which "could cause" obesity, and that obesity is not a determination of the development of diabetes. This is non-responsive to the requested opinion as the examiner did not discuss whether the Veteran's obesity was a substantial factor in his developing DMII. Finally, in response to whether the Veteran's DMII would not have occurred but for his obesity, the examiner simply stated that the Veteran's lifestyle and diet are much larger factors in his development of DMII. Again, this is non-responsive to the opinion requested. Thus, the opinion concerning obesity as an intermediate step is inadequate. 

For these reasons, the Board finds the February 2025 and June 2025 VA opinions to be inadequate and another remand is necessary. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005) (a VA examination must be based on an accurate factual premise). 

The Veteran asserts that he has peripheral neuropathy in his lower extremities that is either directly due to his service, including his TERAs, is secondary to a service-connected disorder, or is secondary to his DMII. The February 2025 VA examiner indicated that the Veteran's lower extremity peripheral neuropathy is diabetic peripheral neuropathy, meaning it is caused by his DMII. As such, the issue of service connection for peripheral neuropathy of the lower extremities is inextricably intertwined with the issue of service connection for DMII, and these claims must also be remanded. 

Finally, the Board observes that the AOJ issued a SSOC in this case in
a VA examination must be based on an accurate factual premise). 

The Veteran asserts that he has peripheral neuropathy in his lower extremities that is either directly due to his service, including his TERAs, is secondary to a service-connected disorder, or is secondary to his DMII. The February 2025 VA examiner indicated that the Veteran's lower extremity peripheral neuropathy is diabetic peripheral neuropathy, meaning it is caused by his DMII. As such, the issue of service connection for peripheral neuropathy of the lower extremities is inextricably intertwined with the issue of service connection for DMII, and these claims must also be remanded. 

Finally, the Board observes that the AOJ issued a SSOC in this case in April 2025. However, the AOJ continued to develop the Veteran's claim for service connection for DMII through at least June 2025 and did not issue an additional SSOC. Rather, the AOJ issued a rating decision in July 2025 that denied service connection for DMII. Of note, it appears that the July 2025 rating decision was adjudicated under the Appeals Modernization Act (AMA) appeals system, however this appeal remains in the Legacy appeals system. It is unclear to the Board why the AOJ issued a rating decision under the incorrect appeal system instead of a SSOC, however, on remand, if the issue is not granted in full, the AOJ must issue a SSOC concerning service connection for DMII and peripheral neuropathy of the lower extremities. 

The matters are REMANDED for the following action:

Forward the claims file to an appropriate clinician, who has not previously participated in this case, to obtain an addendum opinion in order to determine whether the Veteran's diabetes mellitus, type II (DMII) is related to service or a service-connected disability. The record, to include a copy of this Remand, must be made available to and be reviewed by the examiner. A new examination may be ordered if deemed necessary; however, if the Veteran does not attend any scheduled examination related to this Remand, the examiner must provide the requested opinions below. If any requested opinion cannot be rendered, the examiner must explain why providing the opinion is not possible.

After review of the record (and examination if deemed necessary), the examiner should state any and all endocrine disorders found, including DMII. 

Thereafter, the examiner must then opine whether the Veteran's identified DMII began in service, within one year of discharge therefrom, or is otherwise related to military service, to include any toxic exposures therein. 

In addressing the Veteran's toxic exposures, the examiner is asked to consider total potential exposure through all applicable military deployments and the synergistic, combined effect of all toxic exposure risk activities of the Veteran.  The Veteran's in-service exposures include burn pits and other toxins, to include fine particulate matter, as well as exposure to fuel, exhaust, various chemicals/solvents, and minimal asbestos. 

If a direct relationship is not found, the examiner must then opine whether the Veteran's DMII is (a) caused by; or (b) aggravated (i.e., worsened) by his service-connected disabilities, including sleep apnea, lumbar spine strain, and/or left knee patellofemoral syndrome. 

Finally, if the examiner cannot find a direct secondary relationship, the examiner must then consider whether the Veteran's service-connected disabilities have caused his obesity and thus, in turn, caused or aggravated his DMII. In this regard, the examiner should opine as to: (a) whether the Veteran's service-connected disabilities-sleep apnea, lumbar spine, and left knee disorders-have caused or aggravated (i.e., worsened) his obesity. If so, then (b) whether the Veteran's obesity has either caused, substantially contributed to, or otherwise aggravated the Veteran's DMII. And, if so, finally (c) whether the Veteran's DMII would not have occurred if-but-for his obesity due to his service-connected disabilities.

The examiner must also address any lay statements regarding onset of his symptomatology and the continuity of symptomatology since onset and/or since discharge from service.

All findings should be reported in detail and all opinions must be accompanied by a clear rationale. The examiner is reminded that a separate and distinct opinions with supporting rationale are required for all theories of entitlement addressed, including secondary causation and secondary aggravation.

 

 

MARTIN B. PETERS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	K. Pak

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.