Citation Nr: 1802690 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 09-16 691 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for diabetes mellitus, type II, to include as secondary to service-connected hypertension. REPRESENTATION Appellant represented by: Missouri Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. Biggins, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1966 to August 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal from a November 2006 rating decision of the St. Louis, Missouri, Department of Veterans Affairs (VA) Regional Office (RO). The Veteran provided testimony at an August 2009 hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been reviewed and is associated with the claims file. This appeal was most recently before the Board in February 2017 at which time it was remanded for an addendum opinion. As discussed below, the VA opinion provided is not adequate the appeal must be remanded again. See Stegall v. West, 11 Vet. App. 268 (1998). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran's claim was most recently before the Board in February 2017 at which time it was remanded in order to obtain an addendum opinion addressing whether the Veteran's diabetes was etiologically related to his active service or service-connected hypertension. In response to the Board remand a March 2017 addendum opinion was obtained. The opinion provider stated the Veteran's hypertension did not cause or aggravate his diabetes because he was diagnosed with hypertension in 1969 and with diabetes in 2015. Moreover the opinion provider indicated he or she believed that the Veteran's age and obesity caused his diabetes. The opinion provider did not sign the opinion but indicated that he was the examiner who performed the April 2015 VA examination. The Board has repeatedly requested that the opinion provider sign their opinion so that the Board is able to determine whether the opinion was provided by someone competent to provide a medical opinion. See January 2016 and February 2017 Board remands. However, the opinion provider has again failed to sign the provided addendum opinion. The opinion provider noted that he was the examiner who provided the April 2015 VA examination, however, that opinion itself was unsigned making it impossible for the Board to verify this or whether the examiner continued to have the same credentials as noted at the time of the April 2015 VA examination (PA-C). In addition to the lack of identification of the provider, the March 2017 opinion itself is inadequate. The opinion provider did not provide an adequate rationale for his conclusion that the Veteran's diabetes was caused and aggravated by his age and obesity but not his hypertension. Moreover, the opinion provider did not address any of the evidence that the February 2017 Board remand directed him to review. As such, an additional addendum opinion must be obtained on remand. In addition the Veteran appears to continue to receive treatment at a VA medical center. As such, any and all outstanding VA treatment records must be obtained on remand. Accordingly, the case is REMANDED for the following action: 1. Attempt to obtain and associate with the claims file any and all outstanding VA treatment records. 2. After completing the above contact an opinion provider other than the March 2017 opinion provider who wrote the opinion in connection with the Veteran's claim for service connection for diabetes and request an addendum opinion. The Veteran's claims file and copies of all pertinent records must be reviewed by the opinion provider. After a review of the record, the opinion provider should identify the most likely etiology of the Veteran's diabetes. Specifically addressing: (a) Whether it is at least as likely as not (i.e., probability of 50 percent or higher) that the currently diagnosed diabetes is related to the Veteran's period of active service. (b) Whether it is at least as likely as not (i.e., probability of 50 percent or higher) that the Veteran's currently diagnosed diabetes is caused by his service-connected hypertension. (c) Whether it is at least as likely as not (i.e., probability of 50 percent or higher) that the Veteran's currently diagnosed diabetes was aggravated by the Veteran's service-connected hypertension. The examiner is informed that aggravation here is defined as any increase in disability. If aggravation is present, the clinician should indicate, to the extent possible, the approximate level of disability (baseline) before the onset of the aggravation. The opinion provider should consider and discuss as necessary the following: (i) The medical literature referenced in the Veteran's October 2014 Informal Hearing Presentation that discusses the complex relationship between diabetes and hypertension, how hypertension accelerates the course of microvascular and macrovascular complications of diabetes and that hypertension often precedes diabetes mellitus, type II and vice versa; and (ii) The April 2015 Mount Vernon VAMC note indicating the Veteran had trace nonproliferative diabetic retinopathy. A full rationale must be provided for all stated medical opinions that reflects consideration of all lay and medical evidence. The provider of the opinion must be specifically identified. If the opinion provider or the AOJ finds that a new examination is necessary the Veteran should be scheduled for a VA examination. The subsequent examiner should also be asked to answer the questions posed above. 3. Then, readjudicate the issue on appeal. If the benefit remains denied, the Veteran and his representative should be provided a supplemental statement of the case and given an appropriate opportunity to respond. The case should then be returned to the Board for further consideration, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ M.E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).