Citation Nr: 18152025
Decision Date: 11/20/18	Archive Date: 11/20/18

DOCKET NO. 13-18 956
DATE:	November 20, 2018
REMANDED
Entitlement to service connection for diabetes is remanded.
REASONS FOR REMAND
The Veteran served on active duty from June 1976 to May 1982.  This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) San Diego, California.  The Veteran testified before the undersigned Veterans Law Judge in October 2016.    
In February 2018, the Board requested a Veterans Health Administration (VHA) opinion, which was provided in April 2018.  In essence, the Board had sought an opinion to address whether the Veteran developed a liver disability in service; if so, whether it caused or contributed to the Veteran’s development of diabetes; and separately, whether the epidural steroid injections the Veteran received for his service connected back condition aggravated his diabetes.  
In the response to a question concerning liver disability beginning in service, the opinion provider (an endocrinologist), included the comment that she recommended “additional opinion from gastroenterologist/hepatologist.”  The Veteran’s representative requested that the additional opinion be obtained.  In these circumstances, another opinion will be sought.  
In addition, in October 2018, the Veteran’s representative supplemented the record with an opinion from a nurse practitioner of the Gastroenterology and Hepatology Department of the Loma Linda VAMC, to the effect that she thought the Veteran developed liver disease from air gun vaccinations he received in service.  As that conclusion was not adequately explained, this theory of entitlement may be addressed in the opinion being sought.   
The matter is REMANDED for the following actions:
1. Obtain any outstanding relevant VA treatment notes and associate them with the claims file.
2. Invite the Veteran to identify any additional medical treatment records regarding his liver disorder, to include any non-duplicative medical records between 1982 and 1992.  After receiving this information and any necessary releases, contact the named medical providers and obtain copies of the identified medical records which are not already in the claims folder.  
3. Thereafter, arrange for the Veteran's record to be provided to a gastroenterologist/hepatologist for a medical advisory opinion regarding:
a)	whether or not the Veteran developed fatty liver infiltration in service, and if so, is this considered a medical liver condition itself or a symptom of a separate disorder; and 
b)	whether it is at least as likely as not the Veteran developed liver disease from vaccinations with air gun injectors contaminated by the blood of fellow service members.   
The rationale for the opinions provided should be fully set forth.  
4. The AOJ should then review the record and readjudicate the claims remaining on appeal.  If any remains denied, the AOJ should issue an appropriate SSOC (that considers all evidence added to the record since the July 2013 SSOC), afford the Veteran and his representative opportunity to respond, and return the case to the Board.
 
M. E. KILCOYNE
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	M. Colicelli