Citation Nr: 19196954 Decision Date: 12/31/19 Archive Date: 12/31/19 DOCKET NO. 16-11 988 DATE: December 31, 2019 REMANDED Entitlement to service connection for diabetes mellitus, to include as secondary to hepatitis C, chronic kidney disease, or hypertension, is remanded. Entitlement to service connection for hepatitis C, to include as secondary to diabetes mellitus, hypertension, or chronic kidney disease, is remanded. Entitlement to service connection for arthritis (other than in the cervical or lumbar spine), to include as secondary to service-connected cervical or lumbar spine arthritis, is remanded. Entitlement to more than a 10 percent rating for service-connected lumbar spine degenerative disc disease (DDD), is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from June 1977 to September 1977. These matters are before the Board of Veterans’ Appeals (Board) on appeal from February 2014 and August 2014 rating decisions. The undersigned previously remanded these matters in November 2017.   1. Entitlement to service connection for diabetes mellitus, to include as secondary to hepatitis C, chronic kidney disease, or hypertension is remanded. 2. Entitlement to service connection for hepatitis C, to include as secondary to diabetes mellitus, hypertension, or chronic kidney disease is remanded. 3. Entitlement to service connection for arthritis (other than in the cervical or lumbar spine), to include as secondary to service-connected cervical or lumbar spine arthritis is remanded. In its prior remand, the Board sought medical opinions on whether the Veteran’s diabetes mellitus and hepatitis C might be related to each other or his now service-connected chronic kidney disease and hypertension. The Board also ordered an examination to determine whether the Veteran had any arthritis other than service-connected lumbar or cervical spine DDD and, if so, whether such might have been caused or aggravated by the service-connected conditions. Unfortunately, all the opinions obtained on remand are conclusory and offer virtually no explanation for the findings therein. The opinions on diabetes and hepatitis indicates that such disabilities are not caused by one another or service-connected hypertension and chronic kidney disease. The examiner’s rationale indicates that “diabetes is a problem caused by a defect in insulin production in the pancreas. There is no relation to hypertension, or hepatitis C. It can cause chronic kidney disease but is not caused by chronic kidney disease” adding later that “these noted problems do not cause any acceleration of...diabetes mellitus” because there “is no medical evidence which would support this concept.” Similarly, for hepatitis he (or she) indicates that “[h]epatitis C is caused by a specific virus…acquired by such routs as blood transfusions, IV drug use, and other similar such things” and that there “is no relation whatsoever between the etiology of hepatitis C and hypertension, chronic kidney disease, or diabetes.” While the examiner makes motions towards ruling out the relationships in question, the blanket, absolute conclusion he (or she) arrives at for both is facially conclusory and, critically, contradicted by the results of a cursory online search that almost immediately uncovered articles in the National Institute of Health (NIH) database entitled “Diabetes and Hepatitis C: A Two-Way Association” (which notes, in its abstract, that “[m]ost studies…have shown that patients with chronic hepatitis C are more prone to develop type 2 diabetes” and “epidemiological studies have revealed that patients with [type 2 diabetes] may also be at higher risk for worse outcomes of their hepatitis C infection”) and “Diabetes mellitus and hypertension” (which, in its abstract, notes that “[g]lucose intolerance, insulin resistance, and hyperinsulinemia frequently occur with essential hypertension and may be aggravated by hypertension therapy, especially diuretics and beta-blockers.” Surely, if the conclusions in these matters were so obvious and absolute, the examiner would have had little trouble explaining them in more substance so that the Board (and eventually the Veteran) could understand them fully. The examiner makes a similar error when addressing the Veteran’s right shoulder arthritis—opining simply that “[t]hhere [sic] is no conceivable relation either anatomic or physiologic between his spinal problems and the arthritis in his shoulder,” noting that there “are many possible explanations for the shoulder problems but none are related to the spinal difficulties” and finally that there “is no plausible way that the spinal problems could aggravate the shoulder problem.” Again, this is conclusory and, while the examiner does make motions towards underlying “anatomic and physiologic” rationale, he (or she) does not actually discuss them in a way that could be communicated clearly in a proper adjudication of the claim on its merits. Consequently, the Board finds a remand is unfortunately necessary to provide additional clarification. 4. Entitlement to more than a 10 percent rating for service-connected lumbar spine degenerative disc disease (DDD) is remanded. The November 2018 VA back examination report, by the same examiner that delivered the opinions above, indicates no response was provided regarding whether the Veteran has ankylosis of the thoracolumbar spine, and states simply that range of motion testing could not be performed or was not medically appropriate with passive motion and non-weight-bearing but, again, does not explain why. Thus, the Board finds a new examination is unfortunately needed. The matters are REMANDED for the following action: 1. Obtain all updated records (i.e., those not already of record) of VA and adequately identified private treatment the Veteran has received for the disabilities remaining on appeal. 2. Forward the Veteran’s record to an endocrinologist or other appropriate clinician (other than the November 2018 VA examiner) for a medical opinion on the likely cause of his diabetes mellitus. Based on a review of the record, examination of the Veteran, and any tests or studies deemed necessary, the examiner must respond to the following: (a.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that his type 2 diabetes mellitus is CAUSED BY his claimed hepatitis C? (b.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that his type 2 diabetes mellitus is AGGRAVATED (WORSENED BEYOND ITS NATURAL PROGRESSION, REGARDLESS OF PERMANENCE) BY his claimed hepatitis C? (c.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that his type 2 diabetes mellitus is CAUSED BY his service-connected chronic kidney disease? (d.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that his type 2 diabetes mellitus is AGGRAVATED (WORSENED BEYOND ITS NATURAL PROGRESSION, REGARDLESS OF PERMANENCE) BY his chronic kidney disease? (e.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that his type 2 diabetes mellitus is CAUSED BY his service-connected hypertension, to include its treatment or medications? (f.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that his type 2 diabetes mellitus is AGGRAVATED (WORSENED BEYOND ITS NATURAL PROGRESSION, REGARDLESS OF PERMANENCE) BY his service-connected hypertension, to include its treatment or medications? All opinions must include a detailed rationale which fully explains the underlying medical bases for all conclusions with citation to supporting medical evidence or literature and reconciliation of all conflicting evidence (such as, but not limited to, the literature referenced in the body of the remand above). Providing an opinion or conclusion without enough explanation may delay processing of the claim and require further clarification. 3. Forward the Veteran’s record to a nephrologist or other appropriate clinician (other than the November 2018 VA examiner) for a medical opinion on the likely cause of his hepatitis C. Based on a review of the record, examination of the Veteran, and any tests or studies deemed necessary, the examiner must respond to the following: (a.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that his hepatitis C is CAUSED BY his claimed type 2 diabetes mellitus? (b.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that his hepatitis C is AGGRAVATED (WORSENED BEYOND ITS NATURAL PROGRESSION, REGARDLESS OF PERMANENCE) BY his claimed type 2 diabetes mellitus? (c.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that his hepatitis C is CAUSED BY his service-connected chronic kidney disease? (d.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that his hepatitis C is AGGRAVATED (WORSENED BEYOND ITS NATURAL PROGRESSION, REGARDLESS OF PERMANENCE) BY his service-connected chronic kidney disease? (e.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that his hepatitis C is CAUSED BY his service-connected hypertension, to include its treatment or medications? (f.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that his hepatitis C is AGGRAVATED (WORSENED BEYOND ITS NATURAL PROGRESSION, REGARDLESS OF PERMANENCE) BY his service-connected hypertension, to include its treatment or medications? All opinions must include a detailed rationale which fully explains the underlying medical bases for all conclusions with citation to supporting medical evidence or literature and reconciliation of all conflicting evidence (such as, but not limited to, the literature referenced in the body of the remand above). Providing an opinion or conclusion without enough explanation may delay processing of the claim and require further clarification. 4. Forward the Veteran’s record to an orthopedic spine surgeon or other appropriate clinician (other than the November 2018 VA examiner) for a medical opinion on the likely cause of his right shoulder osteoarthritis. Based on a review of the record, examination of the Veteran, and any tests or studies deemed necessary, the examiner must respond to the following: (a.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that his right shoulder osteoarthritis is CAUSED BY his service-connected cervical spine arthritis? (b.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that his right shoulder osteoarthritis is AGGRAVATED (WORSENED BEYOND ITS NATURAL PROGRESSION, REGARDLESS OF PERMANENCE) BY his service-connected cervical spine arthritis, to include as a result of compounding upon right shoulder arthritis symptoms (e.g., pain, stiffness, etc.) such that the resultant functional impairment is worse? (c.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that his right shoulder osteoarthritis is CAUSED BY his service-connected lumbar spine arthritis? (d.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that his right shoulder osteoarthritis is AGGRAVATED (WORSENED BEYOND ITS NATURAL PROGRESSION, REGARDLESS OF PERMANENCE) BY his service-connected lumbar spine arthritis, to include as a result of compounding upon right shoulder arthritis symptoms (e.g., pain, stiffness, etc.) such that the resultant functional impairment is worse? All opinions must include a detailed rationale which fully explains the underlying medical bases for all conclusions. Providing an opinion or conclusion without enough explanation may delay processing of the claim and require further clarification. 5. Then, arrange for the Veteran to be examined by an orthopedist to determine the current severity of his service-connected lumbar spine DDD. The examiner MUST ELICIT a complete, detailed subjective history and report, TO INCLUDE BUT NOT LIMITED TO detailed accounts of functioning with repeated use over a period of time or with flare-ups (e.g., estimated limitation of motion, subjective factors such as pain and weakness, or other symptoms). The examiner should also describe all pathology, symptoms (frequency and severity), and functional impairment found on physical examination in enough detail to allow for application of the pertinent rating criteria. Range of motion test results must be recorded in ACTIVE MOTION, PASSIVE MOTION, WEIGHT-BEARING, and NON-WEIGHT-BEARING, including in the opposite, undamaged joint. If it is not feasible to perform range of motion testing in any of these circumstances, the examiner MUST EXPLAIN WHY IN DETAIL. The examiner should also note any further functional limitations due to pain, weakness, fatigue, incoordination, or any other such factors. The examiner MUST ALSO comment on or describe, to the extent possible, the impact the Veteran’s service-connected lumbar spine disability has on his functioning during flare-ups or with repeated use over a period of time. In doing so, the examiner MUST elicit from the Veteran subjective reports of his functioning under such conditions and consider such reports along with the findings on contemporaneous examination and any other pertinent evidence. If the examiner is still unable to provide such an opinion, he or she MUST EXPLAIN WHY IN DETAIL. The examiner should note that the inability to directly observe functioning under such conditions IS NOT a valid reason to avoid providing an opinion in this matter per se. (CONTINUED ON NEXT PAGE)   All opinions must include a detailed rationale which fully explains the underlying medical bases for all conclusions. Providing an opinion or conclusion without enough explanation may delay processing of the claim and require further clarification. VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Yuan, 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.