Citation Nr: 18160978 Decision Date: 12/28/18 Archive Date: 12/28/18 DOCKET NO. 16-61 728 DATE: December 28, 2018 REMANDED Entitlement to service connection for diabetes mellitus (DM II), to include as secondary to service-connected hypertension, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1977 through February 1978. 1. Entitlement to service connection for DMII, to include as secondary to service-connected hypertension. Remand is required for an adequate VA examination and etiological opinion. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). The central issue in determining probative value of a medical opinion is whether the examiner was informed of the relevant facts. Nieves-Rodriguez, 22 Vet. App. at 302-04. In a secondary service connection claim, a medical opinion that a disorder is not the result of an already service-connected disability does not address the issue of aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). Additionally, although obesity is not a disability for VA purposes, it could qualify as an “intermediate step” between a service-connected disability and a current disability that may be service connected on a secondary basis under 38 C.F.R. § 3.310(a). See VAOGCPREC 1-2017 (Jan. 6, 2017). In a May 2013 e-mail, a VA Physician PP opined that the Veteran’s DMII was less likely than not the result of his service-connected hypertension. The Dr. PP noted that there are multiple risk factors for DMII, such as genetic influences, body habitus, medication effects, pancreatic injury or infection, and concluded that hypertension was not a recognized risk factor. The Board finds that this opinion is not adequate because it isn’t clear that the examiner reviewed the relevant evidence of record, the examiner did not address whether hypertension aggravated the DM II, and the supporting explanation does not consider articles the submitted by the Veteran after the opinion that suggest a greater chance of developing DM II if the patient has hypertension. See September 2011 private medical records; August 2016 private medical records. Finally, although the May 2013 VA opinion noted body habitus is a risk factor for DMII, it did not consider whether body habitus was an intermediate step between his service-connected hypertension and current DMII disability. The Board notes that the Veteran’s entrance examination shows he weighed 154 pounds, at separation he weighed 154 pounds, and from August 2015 through May 2016 he weighed between 207 and 225 pounds. Accordingly, remand for a VA examination and opinion is required. 2. Entitlement to a TDIU. The Veteran’s claim for a TDIU is inextricably intertwined with the now remanded claim for service connection for DMII, to include as secondary to service-connected hypertension. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that issues are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other). Accordingly, remand is required.   The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. Obtain the Veteran’s service treatment records. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his or her representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his diabetes mellitus. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. (a.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the diabetes mellitus had onset in, or is otherwise related to, active military service. (b.) The examiner must also provide an opinion whether it is at least as likely as not (50 percent or greater probability) that the diabetes mellitus is caused or aggravated by the service-connected hypertension. (c.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) the service-connected hypertension caused the Veteran’s obesity? (d.) Next, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) the obesity was a substantial factor in causing DM II. (e.) Finally, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that DM II would not have occurred but for the obesity. The examiner must specifically address the Veteran’s assertions that that a VA Medical Center Nurse Practitioner, SS, stated his hypertension was definitely related to his heart, diabetes mellitus, and kidney disease, and the September 2011 and the August 2016 private medical records discussing hypertension as a risk factor for diabetes mellitus. 4. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2017). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Martinez, Associate Counsel