Citation Nr: 21000485 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 15-15 534 DATE: January 5, 2021 REMANDED Entitlement to service connection for diabetes mellitus type I is remanded. REASONS FOR REMAND The Veteran served on active duty from February 2002 to February 2006. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2012 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). In December 2016, the Veteran provided sworn testimony before the undersigned Veterans Law Judge (VLJ) at a Board hearing. A copy of the hearing transcript has been associated with the electronic claims file. In an August 2018 Board decision, service connection for sleep apnea was dismissed, and service connection claims for diabetes and PTSD were remanded for further development. Subsequently, in an August 2020 rating decision, service connection for PTSD was granted with a 30 percent evaluation effective August 24, 2011, and increased to a total 100 percent evaluation effective August 29, 2019. The Veteran has not appealed this decision, though he is within the one-year time frame to do so, and it therefore is no longer in front of the Board at this time. As to the claim for diabetes, although a VA examination and opinion was obtained in August 2019, with an addendum opinion in June 2020, the Board finds the medical opinions are conclusory and, thus, inadequate for decision-making purposes. Accordingly, the Board finds that remand is necessary in order to obtain an adequate VA medical opinion. Specifically, the opinions provided were conclusory in nature in that the first opinion in August 2019 indicated the diabetes is at least as likely as not due to service as there was an indication of diabetes in 2005 during service. The examiner then opined it was less likely than not due to the weight management program as “his obesity is likely the main cause of DM, [and] the weight management program likely helped his DM condition, not caused or aggravated it.” The opinion also included that the VA Move/Weight Management program “appears to be based on lifestyle changes…not adding supplements.” However, this is not what was asked; the VA Move/Weight Management Program was after service, and the examiner failed to discuss the program the Veteran had undergone during service, and did not discuss the Veteran’s sworn statements that he felt coerced/pressured to take supplements as part of the program. The examiner also stated he was “not aware of weight loss supplements that can cause DM or makes diabetes worse” but does not actually cite to any medical literature or discuss the American Diabetes Association article the Veteran’s representative discussed in the 2016 Board hearing stating otherwise. The RO then requested an addendum opinion, as the first opinion that the Veteran had a diabetes diagnosis during service was not factually shown. Therefore, in a June 2020 addendum opinion, another examiner noted the Veteran’s hemoglobin A1C level was normal and it was five years post-service that he was diagnosed with diabetes mellitus type I and as this occurred after he left the military, the examiner provided a negative nexus opinion. However, this is also inadequate as this opinion simply stated facts without a valid discussion; failed to note that in August 2002, the Veteran’s glucose testing was borderline pre-diabetic (98 with pre-diabetic being 100) and in September 2005 following hemoglobin testing, his results indicated that his HGB A1C level was 5.7 and the interpretation was that “diabetic patients in good control may have Hgb A1C values in the normal range. When using HbA1C to monitor the diabetic patient, results must be interpreted on an individual basis.” Although this may have been the reference to diabetes in service indicated by the 2019 examiner, that is not entirely clear, nor is there a discussion interpreting such as noted and requested. Further, this notation by the 2005 military doctor coincides with the Veteran’s contentions that he felt coerced and pressured to supplement his weight loss, and that following service after being in the weight managements program where he was working out several times a day (aka in “good control”), he gained 100 pounds within one year. He also provided sworn testimony that dieticians and endocrinologists have stated the extreme nature of his routine while in service and then that coming to a halt affected his endocrinology later on. Although this is hearsay as the Veteran has not submitted specific statements from medical providers stating such, this should be considered. As such, the Board finds that the VA examiners failed to expressly opine, with a clear rationale, whether any of the in-service complaints, findings and/or treatment for any potentially pre-diabetic symptoms are etiologically related to his current diabetes disability. Additionally, the Board notes that the fact the Veteran’s condition was normal at discharge does not preclude service connection being granted for a post-service condition if it is, in fact, related to service. An opinion discussing the medical onset for diabetes type I is required. In sum, although the Board sincerely regrets the additional delay, another remand is necessary. The matters are REMANDED for the following action: 1. Request the private medical records the Veteran referenced from private endocrinologists and dietary nutritionists. After securing the necessary releases, attempt to obtain and associate those identified treatment records with the claims file. If any identified records cannot be obtained and further attempts would be futile, such should be noted in the claims file and the Veteran should be notified so that he can make an attempt to obtain those records. 2. DO NOT SCHEDULE THE FOLLOWING until any records identified by the Veteran have been obtained, to the extent possible. 3. Obtain an addendum opinion from an appropriate examiner, preferably an endocrinologist if available, to determine the nature and etiology of the Veteran's diabetes mellitus. Examination of the Veteran is not required unless the examiner determines that an examination is necessary to provide a reliable opinion. Following a review of the claims file, to include a copy of this remand, the examiner is asked to opine as to: a.) whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s diabetes mellitus type I manifested in or is otherwise etiologically related to service? b.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s diabetes mellitus type I was caused by the weight management program he underwent in service, including taking any supplements? The examiner is asked to consider: • August 2002 blood test results indicated his glucose level was at 98 and he was put in the weight loss program; • September 2003, he had a diabetes check and placed on a lower calorie and high fiber diet; • August 2004 active medical conditions included obesity and dietary surveillance and counseling; • November 2004, he reported his mother had a history of diabetes; • February 2005 triglyceride levels were 66; HGB A1C level was 5.7 and the interpretation was that “diabetic patients in good control may have Hgb A1C values in the normal range. When using HbA1C to monitor the diabetic patient, results must be interpreted on an individual basis.” • September 2005 indicated he gained 16 pounds in one week; • January 2006 STR showed his endocrine system was within normal limits; • His diagnosis of uncontrolled diabetes in 2010; • The April 2015 statement from the Veteran, where he stating that during his ongoing weight loss program in the military, he was eventually “asked to obtain these over the counter weight loss aids (with ephedra ingredients) and continue to perform physical fitness routines several times a day” and that following service, he “began to gain weight at a significant rate causing health complications.” • The December 2016 sworn testimony where the Veteran stated he had weight problems during service and that he took ephedra and Hydroxycut to help lose the weight. He testified having jitters and rapid heart rate and sweating after taking these pills. He stated he requested the blood work to be tested as his mother had gestational diabetes and other people with a similar weight issue in service had tested positive for diabetes after leaving service. He stated he had had symptoms such as thirst, fluctuations in weight, and frequent urination for years prior to the 2010 diagnosis. • He also stated during the 2016 hearing that he has been told by dieticians and endocrinologists have told him that the extreme nature of his routine during service could have caused metabolic issues that resulted in diabetes, and that he gained about 100 pounds within the first year post-service. See also reference by Veteran’s representative at the 2016 Board hearing to an article by the American Diabetes Association about ephedra use by people who have diabetes or are pre-diabetic. All opinions must be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. The examiner is cautioned against focusing his/her opinion solely on the evidence of record of a normal separation examination but must consider potential pre-diabetic symptoms and a discussion of this individual’s particular condition. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G.Hoy, Associate 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.