Citation Nr: 18146592 Decision Date: 10/31/18 Archive Date: 10/31/18 DOCKET NO. 16-20 311 DATE: October 31, 2018 REMANDED Issue of entitlement to an increased rating in excess of 20 percent for diabetes mellitus, type II, is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1966 to January 1970, from January 1974 to January 1978, and from January 1978 to August 1991. The Veteran died in August 2016 and the Appellant is his widow. The Appellant was properly substituted and notified in a January 2017 correspondence from the Regional Office (RO). This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2012 rating decision issued by the Department of Veterans Affairs (VA). The Veteran perfected his appeal. See September 2013 Notice of Disagreement (NOD); March 2016 Statement of the Case (SOC); May 2016 VA Form 9. Issue of entitlement to an increased rating in excess of 20 percent for diabetes mellitus, type II. The Board cannot make a fully-informed decision on the issue of entitlement to an increased rating in excess of 20 percent for diabetes mellitus, type II, because an VA examiner addendum opinion is needed to clarify whether the Veteran’s symptoms manifest to warrant a 40 percent rating at any time during the period on appeal and, if so, when. The Veteran was afforded a VA examination for diabetes in March 2011, but the evidence suggests the Veteran may have worsened since. At that time, the VA examiner noted that the Veteran’s medical condition did not prevent him doing a job that requires him to be on his feet all day. See March 2011 VA examination. The VA examiner also noted that the Veteran uses several medications for diabetes, but did not indicate being prescribed injectable insulin. Id. However, in later statements, the Veteran relate to being taken off his oral diabetic medications in late 2011 because they did not control his blood sugar levels and his doctor started him on prescribed insulin shots twice a day. See September 2013 NOD; May 2016 VA Form 9. The Veteran’s lay statements are consistent with a June 2012 VA treatment record indicating the Veteran is taking Lantus and Byetta for his diabetes. Thus, the Board finds an addendum opinion is needed to assess the available evidence of any complications and symptoms from the Veteran’s diabetes mellitus, type II, throughout the period on appeal. The Board acknowledges that the claims file contains two private treatment provider opinions, but finds that both are unclear as to whether the Veteran’s symptoms meet the criteria for a rating in excess of 40 percent for diabetes mellitus. The September 2015 opinion from private treatment provider H.K., M.D., recommends the Veteran no longer be allowed to continue his full time job and that even limited duty to five to six hours per day could compromise his long term health and well being. The March 2016 opinion from W.H., M.D., indicates that the Veteran’s activity is limited due to persistent neuropathy, which is common in late diagnosed diabetes. Dr. W.H. also submitted an excerpt from the March 2016 SOC in which he circled and initialed the 40 percent rating criteria for diabetes mellitus. See May 2016 Correspondence. However, Dr. H.K.’s opinion indicates that his recommendation is based on the Veteran’s neck, bilateral shoulder, bilateral knee, and low back pain, with no mention of the Veteran’s diabetes. Likewise, Dr. W.H.’s opinion indicates that his recommendation for limited activity is due to neuropathy. While neuropathy may have resulted from the Veteran’s diabetes, it is a separate, service connected, disability and it is prohibited to consider the same symptom under various diagnoses. See February 2016 rating decision; 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Thus, the Board finds that further development of the Veteran’s diabetes mellitus symptoms is needed. The matter is REMANDED for the following action: 1. Ask the Appellant to identify the provider(s) of any evaluations and/or treatment received for diabetes that is not already part of the claims file. For any private treatment records, ask the Appellant to provide authorizations for VA to obtain the records. Obtain the complete clinical records of all pertinent evaluations and treatment (records of which are not already associated with the claims file) from the providers identified. If any records sought are unavailable, the reason for their unavailability must be noted in the claims file. If a provider does not respond to VA’s request for the identified records sought, the Appellant must be so notified and reminded that it is ultimately her responsibility to ensure that private treatment records are received. 2. After any outstanding treatment records are associated with the claims file, obtain an addendum opinion from a VA examiner to determine the severity of the Veteran’s service-connected diabetes mellitus throughout the period on appeal, from August 2010 through August 2016. The entire claims folders and a copy of this remand must be made available to the examiner. After reviewing the claims file, the examiner should describe all complications and symptoms related to the Veteran’s service connected diabetes mellitus. The examiner should specifically answer whether the Veteran’s diabetes mellitus required: (a) one or more daily injection of insulin, (b) a restricted diet, and (c) a regulation of activities (defined as avoidance of strenuous occupational and recreational activities). If possible, the examiner should opine on whether any regulation of activities is due to diabetes or another disability. The examiner must provide a rationale for each of the opinions that takes into account the Veteran's reports of his history and current symptoms. The reasons and bases for each opinion are to be fully explained with a complete discussion of the evidence and sound medical principles, which may reasonably explain the medical guidance in the study of this case. 3. Advise the Appellant that she may submit a supplemental medical opinion from a treating physician or any other medical professional that addresses any complications and symptoms related to the Veteran’s service connected diabetes mellitus during the period on appeal from August 2010 to August 2016. If such an opinion is provided, the treating physician (or any other medical professional) should set forth in the medical report a fully articulated rationale for the opinion expressed. The report should consider and discuss the Veteran’s medical history and relevant clinical data that apply in this case, which may reasonably explain the medical guidance in the study of this case. 4. After the above development has been completed, review the record and ensure that all development sought in this remand has been completed. Arrange for any further development indicated by the results of the development requested above and re-adjudicate the claims. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Lin, Associate Counsel