Citation Nr: 19166310 Decision Date: 08/27/19 Archive Date: 08/27/19 DOCKET NO. 17-34 678 DATE: August 27, 2019 REMANDED Entitlement to service connection for type 2 diabetes mellitus, to include as secondary to service-connected hypertension, is remanded. REASONS FOR REMAND The Veteran had active service from June 1974 to October 1974 and from June 1979 to July 1986, with additional Reserves service. This matter was previously remanded by the Board in December 2018 for additional development. As discussed herein, there has not been substantial compliance with prior remand directives, and an additional remand is required. Entitlement to service connection for diabetes mellitus, to include as secondary to service-connected hypertension, is remanded. Unfortunately, the Veteran’s claim of entitlement to service connection for diabetes mellitus, to include as secondary to service-connected hypertension, must again be remanded to comply with remand directives articulated by the Board in December 2018 regarding an adequate medical opinion. See Stegall v. West, 11 Vet. App. 268 (1998). The Board’s December 2018 remand instructions specifically directed that the Veteran was to be afforded a VA examination regarding his reopened service connection claim. The examiner was directed to address the etiology of the Veteran’s diabetes mellitus, including whether it is directly related to his active service, including exposure to chemical and nuclear weapons, or whether it is secondary to his service-connected hypertension. In providing the requested opinions, the VA examiner was asked to specifically consider and discuss relevant evidence of record, including an April 2006 private nexus opinion that the Veteran’s exposure to chemical and nuclear weapons during active service could have contributed to his diabetes mellitus, as well as the Veteran’s April 2004 testimony and the December 2010 private nexus opinion that the Veteran’s service-connected hypertension contributed to his development of diabetes mellitus. In April 2019, the Veteran was examined regarding his claimed diabetes mellitus. Initially, the Board notes that there is some apparent inconsistency within the resulting VA examination report and the opinions provided. For example, the VA examination report indicates that the Veteran does not have any recognized complications of diabetes mellitus (including hypertension); however, the evidence of record clearly indicates that the Veteran has been diagnosed with hypertension, and this disability is service connected. The relevant question in this matter is whether or not the Veteran’s diabetes mellitus is related to active service and/or caused or aggravated by the service-connected hypertension. The examination report goes on to document the examiner’s findings that the Veteran does not have any conditions that are at least as likely as not due to diabetes mellitus (including hypertension), and that the Veteran’s diabetes mellitus has not at least as likely as not permanently aggravated any conditions (including hypertension). Additionally, the VA examiner appears to have rendered conflicting positive and negative nexus opinions. The examiner first opined that the Veteran’s diabetes mellitus was less likely than not incurred in or caused by the claimed in-service injury, event, or illness (a direct service connection opinion) as there is no evidence of record that the Veteran was diagnosed and treated for diabetes during service. The examiner also opined that although there is evidence that hypertension and diabetes overlap in their etiology and disease mechanisms, as well as their coexistence in patients, there is no evidence that one causes the other. The examiner reasoned, based upon a review of records and the Veteran’s history, that diabetes was not diagnosed until 2002, which is 30 years after discharge from service; therefore, a nexus has not been established. Yet, in another portion of the same examination report, the examiner stated that, regardless of an established baseline condition, the Veteran’s claimed condition was at least as likely as not aggravated beyond its natural progression by his service-connected hypertension. As a rationale, the examiner stated that the Veteran’s treatment records reflect renal insufficiency, which would link the Veteran’s diagnoses of diabetes mellitus and hypertension. The examiner stated that diabetes can cause or aggravate hypertension due to diabetes adversely damaging the arteries, specifically in the kidneys, causing a condition known as diabetic nephropathy, which in turn can lead to the development or aggravation of hypertension. Therefore, the, examiner stated that in view of the fact that the Veteran has a diagnosis of renal insufficiency, a nexus has been established. Given the inconsistency within the April 2019 examination report, the Board affords it little probative value and finds it insufficient to warrant a grant of the Veteran’s claim. Moreover, the April 2019 examiner did not specifically discuss the April 2006 private nexus opinion that the Veteran’s exposure to chemical and nuclear weapons during active service could have contributed to his diabetes mellitus, as well as the Veteran’s April 2004 testimony and the December 2010 private nexus opinion that the Veteran’s service-connected hypertension contributed to his development of diabetes mellitus. As such, the Board finds that the April 2019 opinion does not substantially comply with the Board’s remand directives, and an addendum opinion must be sought upon remand. In June 2019, VA obtained a medical opinion from a different examiner, who also provided a negative nexus opinion that the Veteran’s diabetes was not at least as likely as not aggravated beyond its natural progression by the service-connected hypertension. This examiner reasoned that hypertension has no bearing on blood sugars; therefore, it does not aggravate diabetes mellitus. Additionally, the examiner stated that a review of current medical literature does not support such a relationship. As above, the June 2019 examiner did not specifically discuss the April 2006 private nexus opinion that the Veteran’s exposure to chemical and nuclear weapons during active service could have contributed to his diabetes mellitus, as well as the Veteran’s April 2004 testimony and the December 2010 private nexus opinion that the Veteran’s service-connected hypertension contributed to his development of diabetes mellitus. As such, the Board finds that the June 2019 opinion also does not substantially comply with the Board’s remand directives, and an addendum opinion must be sought upon remand. The Board is also mindful that the Veteran’s attorney submitted a June 2019 request for the curriculum vitae or equivalent information regarding the April 2019 and June 2019 VA examiners in order to assess their education, training, and experience. The attorney stated that unless such information was provided, the Veteran would challenge the competency of both examiners to provide a medical opinion. Thereafter, in August 2019, the Board advised the Veteran’s attorney that no documents would be sent in response to his June 2019 request, as the Board does not gather or maintain documents regarding VA examiners. Nevertheless, given the Board’s decision herein to remand this matter for additional development, the Board also finds it prudent that the claims file should be provided to a new VA examiner with relevant expertise in endocrinology. The matters are REMANDED for the following action: Provide the Veteran’s claims file to a new VA examiner (other than those who provided the April 2019 and June 2019 medical opinions) with specific expertise in endocrinology for an addendum opinion regarding the Veteran’s claim of entitlement to service connection for diabetes mellitus, to include as secondary to service-connected hypertension. If the examiner finds that an in-person examination is warranted, then schedule the Veteran for a VA diabetes mellitus examination. The examiner is informed of the following facts: • The Veteran served on active duty from June 1974 to October 1974 and from June 1979 to July 1986. • The Veteran had elevated blood pressure readings while in service but was not diagnosed with hypertension at that time. See VBMS entries with document type, “STR – Medical,” receipt dates 02/29/1988 and 12/02/2008. • A June 2002 private medical record indicates that the Veteran reported he had been diagnosed with hypertension “about 12 years ago,” which would place the diagnosis in approximately 1990. See VBMS entry with document type, “Medical Treatment Record – Non-Government Facility,” receipt date 10/29/2002, on page 1. • Private medical records show that the Veteran was diagnosed with type 2 diabetes mellitus in July 2002. See VBMS entry with document type, “Medical Treatment Record – Non-Government Facility,” receipt date 10/29/2002, on page 7. • In April 2004, the Veteran provided testimony before VA as to the onset of his high blood pressure. See VBMS entry with document type, “Hearing Testimony,” receipt date 04/06/2004. • In an April 2006 letter, a private physician, Dr. WLM, wrote that the Veteran was under his care and was a nuclear weapons specialist while in service, where he was responsible for handling chemical weapons and was exposed to nuclear weapons. He wrote, “This exposure could have contributed to his acquiring diabetes.” See VBMS entry with document type, “Medical Treatment Record – Non-Government Facility,” receipt date 04/21/2006. • In a December 2010 letter, Dr. WLM wrote that the Veteran had a long history of high blood pressure, which Dr. WLM wrote the Veteran had had since 1981. He also noted that the Veteran had a diagnosis of diabetes mellitus and that high blood pressure and diabetes “can be part of the metabolic syndrome.” He wrote, “There is a high probability that the [Veteran]’s service connected development of [high blood pressure” contributed to the development of the [Veteran]’s Type I Diabetes Mellitus.” See VBMS entry with document type, “Medical Treatment Record – Non-Government Facility,” receipt date 03/25/2011. • The Board notes that Dr. WLM’s statement that the Veteran was diagnosed with high blood pressure (assuming he meant hypertension) in 1981 does not appear to be accurate, as the Veteran was in service at that time, and he was not diagnosed with hypertension while in service. The Board finds that the Veteran’s June 2002 report of being diagnosed with hypertension 12 years prior is the most accurate history of when he was diagnosed with hypertension, which would have been in approximately 1990. • The examiner's review of the record is NOT restricted to the evidence listed above. This list is provided in an effort to assist the examiner in locating potentially relevant evidence. The examiner is asked to provide the following opinions: a) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s diabetes mellitus is related to his period of active duty, which was from June 1974 to October 1974 and from June 1979 to July 1986. b) If the answer to (a) is negative, is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s diabetes mellitus is caused by his service-connected hypertension. c) If the answer to (b) is negative, is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s diabetes mellitus is aggravated by his service-connected hypertension. d) If the examiner finds that the service-connected hypertension aggravates the Veteran’s diabetes mellitus, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the diabetes mellitus prior to aggravation. If the examiner is unable to establish a baseline for diabetes mellitus prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. In rendering these opinions, the examiner is asked to specifically consider and discuss relevant evidence of record, including the April 2006 private nexus opinion that the Veteran’s exposure to chemical and nuclear weapons during active service could have contributed to his diabetes mellitus, as well as the Veteran’s April 2004 testimony and the December 2010 private nexus opinion that the Veteran’s service-connected hypertension contributed to his development of diabetes mellitus. The examiner is further advised that an opinion which fails to discuss this specific evidence will likely be found inadequate to adjudicate the Veteran’s claim. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Chad Johnson, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.