Citation Nr: 21065237 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 15-09 371 DATE: October 25, 2021 REMANDED The appeal as to the claim of entitlement to service connection for diabetes mellitus type II is remanded. The appeal as to the claim of entitlement to service connection for hypertensive retinopathy, as secondary to diabetes mellitus type II, is remanded. The appeal as to the claim of entitlement to service connection for a heart disorder, as secondary to diabetes mellitus type II, is remanded. The appeal as to the claim of entitlement to service connection for hypertension, as secondary to diabetes mellitus type II, is remanded. The appeal as to the claim of entitlement to service connection for a cholesterol disorder, as secondary to diabetes mellitus type II, is remanded. The appeal as to the claim of entitlement to service connection for peripheral neuropathy of the bilateral upper extremities, as secondary to diabetes mellitus type II, is remanded. The appeal as to the claim of entitlement to service connection for peripheral neuropathy of the bilateral lower extremities, as secondary to diabetes mellitus type II, is remanded. REASONS FOR REMAND The Veteran had active service in the United States Army from January 1992 to June 1992. The matters are on appeal from a February 2014 rating decision. In an August 2018 decision, the Board denied the Veteran's claim of entitlement to service connection for diabetes mellitus type II, hypertension, hypertensive retinopathy, a heart disability, a cholesterol disability, and peripheral neuropathy of bilateral upper and lower extremities, and dismissed the claim of entitlement to service connection for renal dysfunction as secondary to diabetes mellitus, type II. The Veteran appealed that decision to the Court of Appeals for Veterans Claims (CAVC); and in July 2019, the parties filed a Joint Motion for Remand (JMR) which was granted by the CAVC in a July 2019 Order. The parties to the JMR determined that the Board failed to address a November 2015 lay statement on the Veteran's claimed medical expertise and training as a paramedic; an October 2013 lay statement indicating that the Veteran was relaying an in-service diagnosis of diabetes; and a November 2015 lay statement on claimed continuity of symptomatology. The JMR also noted that the Board failed to determine whether an examination was warranted in adjudicating the claim. 1. Entitlement to service connection for diabetes mellitus type II. The Veteran contends that his current diabetes mellitus type II disorder had its onset during active service. Specifically, in October 2013 and November 2015 statements, he reported that he was diagnosed with diabetes at Fort Jackson in February 1992. In this regard, he reports that he sought treatment from an ophthalmologist for blurred and fluctuating vision, fatigue, and reportedly, black-outs. The Veteran also reports that he continued to have periods of blurred vision and fatigue since then, to the present day. Service treatment records include the report of a September 1991 induction examination that notes the Veteran's report of eye trouble. In this regard, an October 1986 private treatment record shows the Veteran underwent outpatient surgery for left eye alignment (lazy eye). A February 1992 service treatment record shows the Veteran sought treatment for blurry vision. The record contains a notation of "Diabetes PFG diabetes." The examiner assessed macular drusen. Post-service treatment records include a March 1997 record that includes a physician's order to obtain a fasting blood sugar test once a week for four weeks and a two-hour fasting glucose test once a week for four weeks. An April 1997 record includes the physician's note of "second request" for a fasting blood sugar test once a week for four weeks and a two-hour fasting glucose test once a week for four weeks. A March 1999 record indicates a diagnosis of diabetes mellitus type II, following a glucose test. A December 1999 treatment record notes an assessment of mild macular drusen, but "no ocular diabetic." Subsequent records show ongoing treatment for diabetes mellitus type II. In October 2013, the Veteran's mother and sister submitted statements noting that they spoke with the Veteran during his active service, and they recalled the Veteran's complaints of blurry vision and falling asleep while driving. Pursuant to a December 2019 Board remand directive, a VA examiner reviewed the record and provided an opinion in February 2020. The examiner noted a diagnosis of diabetes mellitus type II and opined that it was less likely than not incurred in or caused by an event in service. In providing the opinion, the examiner noted that the service treatment records were negative for complaints of, treatment for, or a diagnosed of diabetes mellitus type II. The examiner further noted that an initial diagnosis of diabetes mellitus type II was documented in June 2012 and concluded that the medical evidence of record did not demonstrate continuous ongoing medical treatment or aggravation of acute or chronic diabetes during the time of discharge from active service, to the present day. The Board found the February 2020 VA opinion inadequate to adjudicate the claim, as the examiner failed to address the February 1992 service treatment record noting the Veteran's report of blurry vision, and the Veteran's assertions of symptoms of blurry vision and fatigue during and after service. Pursuant to a May 2021 Board remand directive, a VA examiner reviewed the record and provided an opinion in July 2021. The examiner opined that it was less likely than not that the Veteran's current diabetes mellitus type II was incurred in or caused by an event in service unless the Veteran's statements are "considered medical facts." In providing the opinion, the examiner noted an "unclear" February 1992 service treatment record regarding a macular drusen and a screening for diabetes. The examiner found that the remaining service treatment records do not contain a diagnosis of diabetes during the Veteran's active service. The examiner concluded that the etiology of diabetes involves complex interactions between environment and genetic factors, to include lifestyle, excessive calorie intake, and obesity, superimposed on a susceptible genotype. The Board finds the July 2021 VA opinion inadequate to adjudicate the claim, as the examiner failed to address the February 1992 service treatment record in the context of the Veteran's consistent complaints of blurry vision and fatigue during service, to the present. Moreover, although the examiner noted an initial post-service glucose test that resulted in a diagnosis of diabetes in March 1999, he failed to address the post-service treatment records dated in March and April 1997, within five years of separation from service, which note the physician's order to obtain a fasting blood sugar test once a week for four weeks and a two-hour fasting glucose test once a week for four weeks. In this regard, the next treatment record of record is the aforementioned March 1999 diagnosis of diabetes, which was assessed following a glucose test. Finally, while the examiner noted risk factors of diabetes, he did not provide an opinion as to the etiology of the Veteran's current diabetes mellitus type II disability. In this regard, he did not address whether the Veteran was obese or had a poor diet. Accordingly, an additional medical opinion is necessary to make a determination in this case. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 2. Entitlement to service connection for hypertensive retinopathy as secondary to diabetes mellitus type II. See argument Below at 7 3. Entitlement to service connection for a heart disorder as secondary to diabetes mellitus type II. See argument Below at 7 4. Entitlement to service connection for hypertension as secondary to diabetes mellitus type II. See argument Below at 7 5. Entitlement to service connection for a cholesterol disorder as secondary to diabetes mellitus type II. See argument Below at 7 6. Entitlement to service connection for peripheral neuropathy of the bilateral upper extremities as secondary to diabetes mellitus type II. See argument Below at 7 7. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities. as secondary to diabetes mellitus type II. The issues of entitlement to service connection for hypertensive retinopathy, heart disorder, hypertension, cholesterol disorder, and peripheral neuropathy of the bilateral upper and lower extremities, are deferred until the claim of entitlement to service connection for diabetes mellitus type II is adjudicated. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely ties together that a final Board decision cannot be rendered unless both are adjudicated). The matters are REMANDED for the following actions: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran's claim, to include any additional records identified by the Veteran. If any requested records are unavailable, or the search for such records otherwise yields negative results, that fact should clearly be documented in the record and the Veteran so notified in accordance with 38 C.F.R. § 3.159(e). All steps taken to attempt to obtain the above records should clearly be documented in the record. 2. All pertinent evidence of record must be made available to and reviewed by an appropriate VA physician who has not provided a prior opinion in this case. The Veteran need not appear for an examination unless deemed necessary by the physician assigned to offer an opinion. Following the review of the record, the physician should provide a medical opinion with respect to the diabetes mellitus type II disorder, present during the period of the claim, as to whether it is at least as likely as not (i.e., at least 50 percent probable) that the diabetes mellitus type II disorder, manifested during, or as a result of, active military service. To the extent possible, the examiner must address whether the Veteran's documented in-service symptom of blurry vision, is an early manifestation of diabetes mellitus type II, or a symptom of macular drusen. In providing the opinion, the examiner must discuss the service treatment record dated in February 1992, that demonstrates the Veteran sought treatment for blurry vision. The examiner must consider the post-service treatment records, to include a March 1997 record that includes a physician's order to obtain a fasting blood sugar test once a week for four weeks and a two-hour fasting glucose test once a week for four weeks; an April 1997 record that includes the physician's note of "second request" for a fasting blood sugar test once a week for four weeks and a two-hour fasting glucose test once a week for four weeks; a March 1999 record that indicates a diagnosis of diabetes mellitus type II following a glucose test; and a December 1999 record that notes an assessment of mild macular drusen, but "no ocular diabetic." The examiner must also consider the Veteran's statements indicating that he experienced ongoing symptoms of blurry vision and fatigue since active service. For purposes of the opinion, the examiner should assume that the Veteran is a credible historian to report on in-service and post-service symptomology he experienced. If the examiner is unable to provide any required opinion, the examiner should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 3. Then, the AOJ should readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran's satisfaction, he and his representative should be provided a supplemental statement of the case and an appropriate period for response before the case is returned to the Board for further appellate action B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Sara Schinnerer, 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.