Citation Nr: 21001172 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 17-31 313 DATE: January 7, 2021 REMANDED Entitlement to service connection for diabetes mellitus, type II (diabetes), including as secondary to service-connected schizophrenia is remanded. Entitlement to service connection for hypertension, including as secondary to service-connected schizophrenia is remanded. REASONS FOR REMAND These matters come before the Board of Veterans’ Appeals (Board) on appeal from a December 2012 rating decision that confirmed and continued previous denials of service connection for diabetes and hypertension. In November 2019, the Veteran and his family member, Ms. F. W. B., testified at a hearing held before the undersigned. In December 2019, the Board allowed reopening of these claims based on the submission of new and material evidence. The issues were remanded for additional development. They are now returned for continued appellate consideration. A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board’s evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). A remand by the Board confers on a Veteran, as a matter of law, a right to compliance with the remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand. If the Board proceeds with final disposition of an appeal, and the remand orders have not been complied with, the Board itself errs in failing to ensure compliance. Stegall v. West, 11 Vet. App. 268, 271 (1998). In March 2009, the Veteran filed a claim seeking service connection for diabetes and hypertension. He asserted these conditions are secondary to medications use to treat his service-connected schizophrenia. In December 2019, the Board observed that the August 2012 VA examinations and etiology opinions obtained to evaluate the Veteran’s claims were inadequate because they did not address both causation and aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136, 138 (2013); Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board remanded the claims so that additional medical opinions, addressing secondary service connection, could be provided. The Board required that these etiology opinions evaluate whether diabetes or hypertension was proximately due to or aggravated beyond their natural progression by schizophrenia, including, but not limited to, the side effects of medications prescribed to treat schizophrenia. The examiner was directed to provide a complete rational for all opinions expressed. 1. Entitlement to service connection for diabetes mellitus, type II (diabetes), including as secondary to service-connected schizophrenia is remanded. Here, VA treatment records include a September 2009 psychiatric admission note documenting a discussion between the Veteran and his VA psychiatrist. The psychiatrist noted the Veteran agreed to a trial of psychiatric medication following a discussion about the “uncontrolled status” of his diabetes and “hazards involved in antipsychotic [prescriptions] relative to his diet and diabetes.” In July 2012, a VA endocrinologist observed, “his psyhe state allows us only so far with his management [of diabetes].” Finally, the August 2012 VA examiner observed medications the Veteran had previously used to treat schizophrenia had potential side effects including diabetes and hyperglycemia. In addition, VA treatment records include an April 2009 VA primary care notation that the Veteran’s diabetes is not controlled. In October 2019, Ms. F. W. B. testified that over time the Veteran used increased medications, including injections, to treat his diabetes. VA treatment records from July 2019 document the Veteran was hospitalized due to a left foot diabetic ulcer and his left great toe was amputated. The Board also notes, in August 2010, the Veteran submitted a list of medical articles indicating an association between diabetes and psychiatric disorders and medications. In January 2020, a VA examiner opined the Veteran’s diabetes was less likely than not proximately due to his service connected schizophrenia. The examiner stated the medical records did not show any association of the onset of diabetes and the Veteran’s use of psychiatric medications. He stated these records did not contain evidence that diabetes or hyperglycemia was caused by medication. The examiner did not address the September 2009 psychiatric admission note, the July 2012 endocrinology note, or the list of medical literature submitted by the Veteran. The January 2020 examiner also opined that diabetes was less likely than not aggravated beyond its natural progression by schizophrenia because there was no “unexpected increased” severity of diabetes. He stated the diabetes was “insulin controlled.” However, the recent amputation of the Veteran’s great left toe indicates his diabetes may not be adequately controlled. These January 2020 etiology opinions do not appear to be based on a complete and accurate evaluation of the Veteran’s medical history. See Stefl, supra; see also Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (indicating an opinion based on an inaccurate factual history is of limited probative value). They are insufficient to evaluate the claim. Moreover, they do not provide the full supporting rationale required in the Board’s prior remand. See Stegall, supra. 2. Entitlement to service connection for hypertension, including as secondary to service-connected schizophrenia is remanded. The August 2012 VA examiner noted the Veteran had taken medication to treat his schizophrenia which had the potential side effect of hypertension. Following the Board’s remand, a January 2020 VA examiner stated there was no objective evidence that the Veteran increased blood pressure was induced by any psychiatric medication. He did not discuss the August 2012 VA examiner’s statement or the Veteran’s specific medical history. The January 2020 VA examiner also opined that the Veteran’s hypertension was less likely than not aggravated beyond its natural progression by schizophrenia because there was on unexpected increase in the severity of hypertension. The examiner did not discuss the course of the Veteran’s hypertension or explain why the severity had not deviated from its natural progression. This opinion is not supported by a complete rationale as required by the Board’s prior remand. Id. The Board notes, the January 2020 examiner also stated the Veteran had multiple medical condition, including diabetes, which could aggravate hypertension. Thus, the claim for service connection for hypertension is intertwined with the claim for service connection for diabetes. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are “inextricably intertwined” when a decision on one issue would have a “significant impact” on a veteran’s claim for the second issue). The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s diabetes is at least as likely as not related to service-connected schizophrenia, including medications used to treat schizophrenia. The clinician must opine whether diabetes is proximately due to schizophrenia (including medications used to treat schizophrenia) or aggravated beyond its natural progression by schizophrenia (including medications used to treat schizophrenia). The clinician must review the entire claims file and specifically address the September 2009 psychiatric admission note, the July 2012 endocrinology note, the August 2012 VA examination report and etiology opinion, and the August 2010 list of medical literature. In discussing whether the Veteran’s diabetes has been aggravated beyond its natural progression, the clinician is asked to address the Veteran’s increased use of medications for diabetes (as indicated in the October 2019 hearing transcript) and his July 2019 left foot diabetic ulcer and left great toe amputation. The opinion must address both causation and aggravation to be deemed adequate. The clinician must be advised aggravation means an increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the clinician should attempt to quantify the degree of additional disability resulting from the aggravation. The examination report (or reports) must include a complete rationale for the opinions provided. If the clinician determines that an additional examination is necessary to provide the opinions requested, schedule an examination. If feasible, schedule a telehealth examination. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s hypertension is at least as likely as not related to service-connected schizophrenia, including medications used to treat schizophrenia. The clinician must opine whether hypertension is proximately due to schizophrenia (including medications used to treat schizophrenia) or aggravated beyond its natural progression by schizophrenia (including medications used to treat schizophrenia). The clinician must review the entire claims file and specifically address the August 2012 VA examination report and etiology opinion. The opinion must address both causation and aggravation to be deemed adequate. The clinician must be advised aggravation means an increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the clinician should attempt to quantify the degree of additional disability resulting from the aggravation. If the clinician determines that an additional examination is necessary to provide the opinions requested, schedule an examination. If feasible, schedule a telehealth examination. 3. If the clinician opines that diabetes is proximately due to or aggravated beyond its natural progression by schizophrenia AND that hypertension is not proximately due to and not aggravated beyond its natural progression by schizophrenia, he or she must opine whether hypertension is proximately due to diabetes or aggravated beyond its natural progression by diabetes. The clinician must review the entire claims file and specifically address the January 2020 VA examiner’s etiology report which identifies diabetes as associated with increased hypertension severity. (Continued on the next page)   The opinion must address both causation and aggravation to be deemed adequate. The clinician must be advised aggravation means an increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the clinician should attempt to quantify the degree of additional disability resulting from the aggravation. If the clinician determines that an additional examination is necessary to provide the opinions requested, schedule an examination. If feasible, schedule a telehealth examination. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Jeanne Celtnieks 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.