Citation Nr: 18145110 Decision Date: 10/30/18 Archive Date: 10/26/18 DOCKET NO. 16-15 871 DATE: October 30, 2018 REMANDED Entitlement to service connection for type II diabetes mellitus is remanded. Entitlement to service connection for an eye disability, claimed as secondary to diabetes, is remanded. Entitlement to service connection for right lower extremity neuropathy, claimed as secondary to diabetes, is remanded. Entitlement to service connection for left lower extremity neuropathy, claimed as secondary to diabetes, is remanded. Entitlement to service connection for a heart disability is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a disability affecting balance, claimed as an equilibrium disorder, is remanded. REMAND Introduction The Veteran served on active duty in the United States Navy from August 1961 to February 1965. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of an August 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. REASONS FOR REMAND At the outset, the Board notes that VA must provide a medical examination or obtain a medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing that certain diseases manifested during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A(d)(2) (2012); 38 C.F.R. § 3.159(c)(4)(i) (2017). The third prong, which requires that the evidence of record “indicate” that the claimed disability or symptoms “may be” associated with the established event, disease or injury is a low threshold. McLendon, 20 Vet. App. at 83. In addition, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). To be considered adequate, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In addition, a medical examiner is not free to simply ignore a veteran’s lay statements recounting symptoms or events. Dalton v. Nicholson, 21 Vet. App. 23 (2007). A review of the record shows the Veteran has been diagnosed with type II diabetes mellitus. He has contended the onset of this condition was during service. Specifically, he has contended that he weighed 145 pounds upon entry, and 280 pounds at discharge, and that his diabetes had its onset due to his rapid in-service weight gain. The Veteran’s service treatment records (STRs) show a “weight problem” was noted in May 1964 and obesity was diagnosed upon re-enlistment in October 1964. To date, no VA medical opinion has been obtained to address the Veteran’s contention. Under these circumstances, the Board finds a remand is warranted to afford the Veteran a VA examination to address his contention that his diabetes was caused by rapid weight gain during service. The record also shows the Veteran has been diagnosed with bilateral lower extremity neuropathy, as well as retinopathy, related to his diabetes. Accordingly, the Board finds the claims for service connection for these conditions must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision on the matter). The record also shows the Veteran suffered a myocardial infarction in 2003 and was subsequently diagnosed with heart disease. He has also been diagnosed with hypertension. He has contended that these conditions also had their onset during service or were caused by rapid in-service weight gain. Alternatively, he has contended that the conditions are secondary to his diabetes. To date, no VA medical opinions have been obtained to address these contentions. Under these circumstances, the Board finds a remand is warranted for a VA examination. Regarding the Veteran’s claim for service connection for an “equilibrium disorder,” the Veteran has contended he suffers from dizziness and loss of balance related to his service-connected bilateral hearing loss and/or tinnitus. In a July 2013 opinion, a VA examiner stated the Veteran’s tinnitus contributed to a poor sense of balance, but found that the poor sense of balance did not warrant a separate diagnosis. The examiner provided no medical explanation for this finding. For this reason, the Board finds the opinion is inadequate for adjudication purposes and that a remand is warranted for an additional VA opinion clarifying whether the Veteran has any diagnosable condition affecting his balance, and, if so, whether the condition is related to his service-connected hearing loss and/or tinnitus. Accordingly, the matters are REMANDED for the following actions: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran’s claims. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Afford the Veteran a VA examination to determine the nature and etiology of his diabetes. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s type II diabetes mellitus had its onset during or is otherwise etiologically related to his military service. In providing his or her opinion, the examiner must address the Veteran’s lay statements to the effect that his diabetes was incurred during service due to rapid weight gain, and went undiagnosed for many years. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 3. Afford the Veteran a VA examination to determine the nature and etiology of all eye disabilities present during the period of the claim. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should identify all eye disabilities present during the period of the claim. Then, with regard to each identified eye disability, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the disability is proximately due to or has been aggravated (permanently worsened beyond its natural progression) by the Veteran’s type II diabetes mellitus. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 4. Afford the Veteran a VA examination to determine the nature and etiology of all bilateral lower extremity neurological disabilities present during the period of the claim. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should identify all right and/or left lower extremity neurological disabilities present during the period of the claim. Then, with regard to each identified lower extremity neurological disability, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the disability is proximately due to or has been aggravated (permanently worsened beyond its natural progression) by the Veteran’s type II diabetes mellitus. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 5. Afford the Veteran a VA examination to determine the nature and etiology of all heart disabilities present during the period of the claim. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should identify all heart disabilities present during the period of the claim. Then, with regard to each identified heart disability, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the disability had its onset during or is otherwise etiologically related to the Veteran’s military service. In providing his or her opinion, the examiner must address the Veteran’s lay statements to the effect that his heart disability was incurred during service due to rapid weight gain. Then, with regard to each identified heart disability, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the disability is proximately due to or has been aggravated (permanently worsened beyond its natural progression) by the Veteran’s type II diabetes mellitus. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 6. Afford the Veteran a VA examination to determine the nature and etiology of his hypertension. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s hypertension had its onset during or is otherwise etiologically related to the Veteran’s military service. In providing his or her opinion, the examiner must address the Veteran’s lay statements to the effect that his hypertension was incurred during service due to rapid weight gain. If not, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s hypertension is proximately due to or has been aggravated (permanently worsened beyond its natural progression) by his type II diabetes mellitus. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 7. Afford the Veteran a VA examination to determine the nature and etiology of any disability affecting balance, claimed as secondary to hearing loss and tinnitus. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should state whether the Veteran has a diagnosable condition which causes dizziness and/or affects balance. If the examiner determines that the Veteran has no separately diagnosable condition causing dizziness and/or affecting balance, he or she should provide a medical explanation for this finding. If the examiner is able to diagnose a condition which causes dizziness and/or affects the Veteran’s balance, he or she should state whether it is at least as likely as not (50 percent probability or greater) that the condition is proximately due to or has been aggravated (permanently worsened beyond its natural progression) by the Veteran’s service-connected bilateral hearing loss and/or tinnitus. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 8. Undertake any other development determined to be warranted. 9. Then, readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran’s satisfaction, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded the requisite opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Hampton, Associate Counsel