Citation Nr: 21067373 Decision Date: 11/04/21 Archive Date: 11/04/21 DOCKET NO. 18-29 217 DATE: November 4, 2021 REMANDED 1. Entitlement to an initial compensable rating for inflammatory bowel disease (IBD) (initially claimed as Crohn's disease) prior to August 11, 2017, is remanded. 2. Entitlement to an initial rating higher than 30 percent for IBD on or after August 11, 2017, is remanded. 3. Entitlement to service connection for diabetes mellitus, to include as secondary to service-connected IBD is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1987 to January 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2015 decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran has a separate appeal involving entitlement to addition of a dependent spouse. This issue is addressed in a separate Board decision. In a March 2018 rating decision, the RO awarded a higher 30 percent rating for IBD from August 11, 2017. Although the RO characterized the issue on appeal to include entitlement to an earlier effective date for the grant of service connection for IBD, the Veteran's attorney specifically contended in the May 2018 correspondence submitted with the substantive appeal (VA Form 9, Appeal to the Board) that the Veteran was seeking entitlement to an earlier effective date for a compensable evaluation for IBD. Specifically, he contended that a compensable rating for IBD should be granted from August 14, 2014. Therefore, the Board has characterized on the title page in accordance with the Veteran's contentions. Within the May 2018 VA Form 9, the Veteran had requested a hearing before the Board. In May 2021, the Veteran withdrew his Board hearing request. A March 2019 Decision Review Officer (DRO) hearing transcript is of record. After the issuance of the March 2018 statement of the case (SOC), relevant VA treatment records were associated with the record. The Veteran also submitted additional evidence. However, as the Board is remanding the claims, the Agency of Original Jurisdiction (AOJ) will have opportunity to review the additional evidence received. See 38 C.F.R. §§ 19.31(b)(1), 19.37(a). Therefore, the Veteran is not prejudiced by the Board reviewing the evidence for the purpose of remanding the claims. 1. Entitlement to an initial compensable rating for inflammatory bowel disease (IBD) prior to August 11, 2017, is remanded. 2. Entitlement to an initial rating higher than 30 percent for IBD on or after August 11, 2017, is remanded. 3. Entitlement to service connection for diabetes mellitus, to include as secondary to service-connected IBD is remanded. In a May 2018 correspondence, the Veteran's attorney contended that a nexus opinion is necessary to provide an etiology opinion for the Veteran's type 2 diabetes mellitus, to include as secondary to service-connected IBD. Notably, the Veteran's attorney submitted medical treatise evidence that supports a correlation between steroid medication and diabetes mellitus, titled: (1) "Steroid hyperglycemia Prevalence, early detection and therapeutic recommendations: A narrative review;" (2) "Gluccocorticoid-induced diabetes mellitus: An important but overlooked problem;" and (3) "Steroid induced diabetes mellitus in patient receiving prednisolone for haematological disorders." STRs from 1989 to 1990 document the Veteran was prescribed and taking Prednisone due to symptoms related to his irritable bowel disease. An October 2013 private treatment record noted the Veteran started Prednisone medication. A January 2016 VA treatment record noted an impression of CD inflammatory burden disease and that a diagnosis was established in the military and that the Veteran was on steroids on and off since 2001. Both private and VA treatment records reflect the Veteran was diagnosed with type I diabetes mellitus. In October 2017, the Veteran's attorney submitted an opinion from the Veteran's treating physician, Dr. Abe Hardoon, that documented the Veteran was diagnosed with type 2 diabetes mellitus that is more likely than not related to service and is more likely secondary to the Veteran's service-connected disability. However, Dr. Hardoon did not provide rationale for the opinions, to include the changed diagnosis from type 1 diabetes mellitus to type 2 diabetes mellitus. Therefore, this opinion is not adequate to support a grant of service connection for diabetes mellitus. The Board finds that a remand is required to obtain an adequate VA examination and opinion that clarifies whether the Veteran has type I or type 2 diabetes mellitus and to address whether the Veteran's diabetes mellitus had its onset in service or is caused or aggravated by his service-connected IBD or the medication, Prednisone, which he takes for his service-connected IBD. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). On this note, the Board finds that there are missing treatment records that are relevant to the issue on appeal. For example, in August 2014, the Veteran completed a VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs, to allow VA to obtain the private treatment records from Dr. Abe Hardoon. The Veteran documented that Dr. Hardoon would have treatment records from March 2004 to May 2013. However, when Dr. Hardoon submitted treatment records, while there are laboratory findings from December 2008, April 2009, July 2009, August 2009, October 2009, February 2010, April 2013, June 2013, the treatment records are from February 2009 related to abnormal liver function and carotid bruit, and April 2013 and October 2013 only, and it is clear that 2009 is not the first time the Veteran was treated by Dr. Hardoon. The Veteran is requested to again provide VA with permission to obtain all the treatment records from Dr. Hardoon beginning in 2004 up to the present time, as the 2021 VA treatment records show that the Dr. Hardoon is still the Veteran's primary care physician. If Dr. Hardoon does not have treatment records earlier than February 2009 and/or between March 2009 and April 2013, Dr. Hardoon should submit a statement under penalty of perjury that he does not have treatment records earlier than February 2009 and between March 2009 and April 2013. Dr. Hardoon has written that the Veteran was diagnosed with diabetes mellitus in 2008, and there is no treatment record supporting this fact (that the Veteran was first diagnosed with diabetes mellitus in 2008). Additionally, a November 2013 private hospitalization discharge summary documents that the Veteran had a history of type 1 diabetes and had been taking oral medication for some time. The examiner wrote, "He had already undergone a left below-knee amputation because of diabetic foot ulcers that had gotten out of control." The examiner also documented the Veteran was "educated extensively about being a type 1 diabetic since this is his second diabetic ketoacidosis admission." The hospitalization records documenting the below-the-knee amputation and hospitalization records from the prior admission due to diabetic ketoacidosis are relevant to the issue on appeal, both of which happened prior to November 2013, and the Veteran should provide VA with permission to obtain the hospitalization records where he underwent the left below-the-knee amputation and had to be admitted due to diabetic ketoacidosis. VA treatment records document that the Veteran underwent an amputation in June 2013 by "Dr. Esmerelde" who is an orthopedic surgeon and name may be actually Dr. Nowokere Esemuede, and was also seeing Dr. Theophilis, whose name may be Dr. Lee Theophelis. The Veteran should provide VA with permission to obtain these records, where he should identify the physicians' names and addresses. Further, VA treatment records document that the Veteran has a non-VA endocrinologist, Dr. Ruben Pipek. These treatment records are relevant also to the Veteran's claim for service connection for diabetes mellitus. The Veteran should provide VA with permission to obtain these records. The lack of medical evidence between service discharge in 1991 and 2013 is concerning, as it is clear that the Veteran has a diagnosis of diabetes mellitus since at least 2008 and such disability requires medical management. The Board requests that the Veteran assist VA in obtaining relevant evidence during this time frame, as there appears to have been a change in his diagnosis from type 1 diabetes mellitus to type 2 diabetes mellitus in 2013, and the facts supporting the change in diagnosis are not in the file. The Veteran should also assist with obtaining treatment records from private providers since 2013. In a March 2015 VA treatment record, it shows the Veteran reported that he was recently awarded Social Security Administration (SSA) disability benefits and that he was expected to receive $1,600.00 in SSA disability income. On remand, the RO should request the Veteran's Social Security Administration (SSA) disability records. The matters are REMANDED for the following action: 1. Obtain the Veteran's Social Security Administration decision, which granted disability benefits, and the medical records relied upon in the determination. All SSA records should be associated with the record. If any of the records requested are unavailable, clearly document the claims file to that effect and notify the appellant of any inability to obtain these records, in accordance with 38 C.F.R. § 3.159(e). 2. Obtain any outstanding VA treatment records since September 2021 and associate them with the claims file. 3. Ask the Veteran to complete and return VA Forms 21-4142, Authorization and Consent to Release Information, for treatment of diabetes mellitus, as well as any other provider that he received treatment for his diabetes mellitus or IBD: Dr. Abe Hardoon from 2004 to the present time (2021). In the letter to Dr. Hardoon, VA should inform him that if does not have treatment records earlier than February 2009 and/or between March 2009 and April 2013, Dr. Hardoon should submit a statement under penalty of perjury that he does not have treatment records earlier than February 2009 and between March 2009 and April 2013; Dr. Esmerelde (possibly Dr. Nowokere Esemuede), who performed an amputation involving the left lower extremity in June 2013; Dr. Lee Theophelis, who treated the Veteran following the June 2013 amputation involving the left lower extremity; Dr. Ruben Pipek, the Veteran's non-VA endocrinologist, all records; and Any other relevant treatment records pertaining to IBD and diabetes mellitus, including, but not limited to, records between service discharge in 1991 and 2013. The Veteran is asked to cooperate with VA's attempts to obtain relevant records. 38 C.F.R. § 3.159(c)(1)(i) (stating, "The claimant must cooperate fully with VA's reasonable efforts to obtain relevant records from non-Federal agency or department custodians. The claimant must provide enough information to identify and locate the existing records, including the person, company, agency, or other custodian holding the records; the approximate time frame covered by the records; and, in the case of medical treatment records, the condition for which treatment was provided.") 4. Schedule the Veteran for a VA examination with a qualified examiner to assist in determining the nature and cause of his diabetes mellitus. All appropriate tests, studies, and consultations should be accomplished, and all clinical findings should be reported in detail. The examiner should be provided a copy of the below facts. To assist the examiner in rendering the requested opinion, the Board provides the following relevant evidence, with citations to the record, where appropriate: The Veteran had active service from January 1987 to January 1991. The Veteran has alleged that his diabetes mellitus is related to service and/or caused or aggravated by a service-connected disability IBD or the medication, Prednisone, taken for his service-connected IBD, which he took during service from 1989 to 1990, and off and on since approximately 2001. The Veteran's service treatment records do not document treatment for or a diagnosis of diabetes mellitus. In a September 1989 STR, the Veteran was prescribed 60 mg of Prednisone for treatment of his ulcerative colitis. See VBMS entry with document type, "STR Medical," receipt date 10/24/2014, with "#1" in the subject field, p. 16. A September 1989 STR noted a finding of presumptive ulcerative colitis and the Veteran was doing much better. He was on Prednisone medication and directed to taper the dosage in milligrams from 40 mg, 30 mg, 20 mg, 15 mg, 10 mg, 5 mg for 5 days at a time for each dosage. See VBMS entry with document type, "STR Medical," receipt date 10/24/2014, with "#1" in the subject field, p. 19. An October 1989 STR follow up on digestive problems noted the Veteran was on 30 mg of Prednisone/day and to continue Prednisone, taper as prescribed. See VBMS entry with document type, "STR Medical," receipt date 10/06/1968, with "#1" in the subject field, p. 18. An October 1989 STR documented a diagnosis of irritable bowel disease, ulcerative colitis from a rectal biopsy. See VBMS entry with document type, "STR Medical," receipt date 10/24/2014, with "#2" in the subject field, p. 38. A November 1989 STR noted gradual return of ulcerative colitis symptoms since stopping Prednisone and tapering medication 2 weeks ago. He was prescribed Prednisone with rapid taper in dosage for 60 mg for 4 days, 50 mg, 40 mg, 30 mg for 2 days each, and then 25 mg, 20 mg, 15 mg, 10 mg, and 5 mg for one day each. He began Azulfidine after completing Prednisone. See VBMS entry with document type, "STR Medical," receipt date 10/24/2014, with "#1" in the subject field, p. 22. A December 1989 STR for follow up on digestive problems noted the Veteran completed Prednisone taper and started Azulfidine. It was noted Prednisone effect was not as dramatic this time, and he lost 3 pounds. He was prescribed another quick taper of Prednisone of 60 mg, 50 mg, 40 mg, 30 mg, 25 mg, 20 mg, 15 mg, 10 mg, 5 mg each. It was noted that if he was unable to wean steroids, enemas, CBC, protein, cholesterol testing would be appropriate. See VBMS entry with document type, "STR Medical," receipt date 10/24/2014, with "#1" in the subject field, p. 23. A December 1989 STR noted ulcerative colitis and the Veteran was currently on 5 mg of Prednisone/day and directed to continue and taper 5 mg, 4 mg, 3 mg, 2 mg, 1 mg for 2 days each. See VBMS entry with document type, "STR Medical," receipt date 10/24/2014, with "#2" in the subject field, p. 84. In Dental Medical Histories completed by the Veteran, the Veteran did not respond that he had diabetes when prompted to circle his disabilities in the dental health questionnaires completed in February 1988, February 1989, and August 1989. See VBMS entry with document type, "STR Medical," receipt date 10/23/2014, with "#1" in the subject field, pp. 37, 39, & 40. A May 1990 STR noted ulcerative colitis condition cleared up on Prednisone and Azulfide and that he was off medications 3 to 4 weeks. See VBMS entry with document type, "STR Medical," receipt date 10/23/2014, with "#1" in the subject field, p. 25. A June 1990 STR noted ulcerative colitis flare-up and the Veteran was taking 500 mg of Azulfidine. He was prescribed Prednisone of 60 mg for 4 days then taper 2 weeks to 0 when diarrhea decreases. See VBMS entry with document type, "STR Medical," receipt date 10/23/2014, with "#1" in the subject field, p. 24. The September 1990 Report of Medical Examination from service discharge shows clinical evaluation of the endocrine system was normal and in the respective physician's summary signed in October 1990, the examiner noted the Veteran denied a personal or family history of diabetes. See VBMS entry with document type, "STR Medical," receipt date 10/23/2014, with "#1" in the subject field, pp. 2, 5 (September 1990, item 33) & 51 (October 1990, item 25). In the corresponding September 1990 Report of Medical History from service discharge, the Veteran denied a history of having sugar in his urine, and he reported he was in good health. See VBMS entry with document type, "STR Medical," receipt date 10/23/2014, with "#1" in the subject field, p. 6 (September 1990, item 11, middle column). There is an absence of medical treatment evidence between service discharge in 1991 and October 2013, and VA is in the process of attempting to obtain evidence between 1991 and 2013. Of record during the time frame from 2008 to 2013 are laboratory results. See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 01/05/2015, pp. 9-19. An October 2013 private treatment record documented the Veteran had significant exacerbation of ulcerative colitis with diarrhea that he had the past 7 to 8 weeks. He started on Asacol 800 mg, as well as Prednisone. Rapid weight loss was noted as most likely secondary to diabetes or more recently secondary to ulcerative colitis. His glucose level was documented at 398. See Medical Treatment Record - Non-Government Facility, Received 01/11/2015, p. 8. A November 2013 hospital discharge summary includes final diagnoses of "Type 1 diabetes, status post diabetic ketoacidosis" and "Type 1 diabetes with A1c of 12 with a history of taking oral medication instead of insulin." The hospital course described the Veteran as a 53-year-old male with a history of type 1 diabetes and that he had already undergone a left below-the-knee amputation because of diabetic foot ulcers that had gotten out of control. The examiner documented the Veteran was "educated extensively about being a type 1 diabetic since this is his second diabetic ketoacidosis admission." See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 04/13/2015, p. 2. A December 2013 hospital discharge summary shows an active issue as "Insulin-dependent diabetes." See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 04/13/2015, p. 4. During the December 2013 hospitalization, the Veteran reported he had type 2 diabetes mellitus. A January 2014 C-Peptide serum shows a test result of 1.6 ng/ML. See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 04/13/2015, p. 8. A January 2014 VA treatment record documents the Veteran reported his glucose readings range from the low 200's to mid-300's with sugar approaching 400 every 2 to 3 days. The Veteran denied hypo/hyperglycemia since hospital discharge. See VBMS entry with document type, "CAPRI," receipt date 03/27/2018, with #1 in the subject field, p. 34. In April 2014, it was noted that all of the Veteran's glucose readings averaged 150 and slightly over 200. Id., pp. 26, 28. 2015 to 2016 VA treatment records appear to document the Veteran was prescribed ocular medication of Prednisolone. See VBMS entry with document type, "CAPRI," receipt date 09/24/2018, with #1 in the subject field, pp. 26, 28. A December 2020 VA treatment record documented the Veteran recorded blood sugar in the 290 to 340s. See VBMS entry with document type, "CAPRI," receipt date 09/20/2021, p. 209. A January 2021 VA treatment record documented that the Veteran was diagnosed with diabetes since 2013. The examiner wrote, "He reports he is Type 2 diabetic[. G]iven that he has been hospitalized x2 in Diabetic ketoacidosis[,] he is a Type 1 diabetic." The examiner noted the Veteran had known anemia, hypertension, Crohn's disease, and chronic kidney disease now in Stage 3B. The examiner further noted the Veteran had multiple family members with diabetes and on insulin. See VBMS entry with document type, "CAPRI," receipt date 09/20/2021, p. 204. A June 2021 VA treatment record noted glucose was under 200. It was 183 that morning. The diabetes was noted as uncontrolled. See VBMS entry with document type, "CAPRI," receipt date 09/20/2021, pp. 168, 183. A July 2021 VA treatment record documented home blood sugar readings were erratic with reported readings ranging 84 to 303. See VBMS entry with document type, "CAPRI," receipt date 09/20/2021, p. 100. August 2021 VA treatment records note the Veteran's diabetes was out of control and the Veteran reported lows of 59 and one of 58 over the last week and sugar ranges 58 to 312 with average blood sugar at 176. See VBMS entry with document type, "CAPRI," receipt date 09/20/2021, pp. 66, 48. The Veteran has submitted three Medical treatise evidence titled: (1) "Steroid hyperglycemia Prevalence, early detection and therapeutic recommendations: A narrative review;" (2) "Gluccocorticoid-Induced Diabetes Mellitus: An Important but Overlooked Problem;" and (3) "Steroid induced diabetes mellitus in patients receiving prednisolone for haematological disorders" addressing the relationship between steroids and diabetes can be found in VBMS entry with document type, "Web / HTML Documents," receipt date 05/20/2021. In an August 2017 "Medical Nexus Opinion," the Veteran's treating physician, Dr. Abe Hardoon, wrote that the Veteran had a current diagnosis of diabetes mellitus type 2. Dr. Hardoon checked a box that stated it was more likely than not that diabetes mellitus type 2 is a result of an event, disease, or injury incurred during active duty military service. He also checked a box that the diagnosis was more than likely secondary to the above noted service-connected disability without a service-connected disability being listed within the document. See VBMS entry with document type, "Disability Benefits Questionnaire (DBQ) Veteran Provided," receipt date 10/04/2017, with "#2" in the subject field. The August 2017 private medical opinion did not properly address whether the Veteran's service-connected IBD or the medication he takes for his service-connected IBD caused or aggravated his diabetes mellitus or provide an explanation. To reiterate, VA is in the process of obtaining additional relevant private treatment records. The Veteran has a non-VA endocrinologist, whose records VA has requested that the Veteran assist in obtaining. VA is also attempting to get the hospitalization records from the Veteran's June 2013 left lower extremity amputation and a hospitalization prior to November 2013 involving diabetic ketoacidosis (the November 2013 hospitalization was documented to be the Veteran's second hospitalization involving diabetic ketoacidosis). The examiner's review of the record is NOT restricted to the evidence listed above. This list is provided to assist the examiner in locating potentially relevant evidence. The VA examiner is requested to opine as to the following: (1) Please state whether the Veteran has a diagnosis of type I or type 2 diabetes mellitus. For example, is diabetic ketoacidosis indicative of type 1 or type 2 diabetes mellitus? Is a diagnosis of "insulin-dependent diabetes" (as shown in the December 2013 hospitalization summary discharge report) indicative of type 1 or type 2 diabetes mellitus? Is a C-Peptide serum finding of 1.6 ng/ML indicative of type 1 or type 2 diabetes mellitus? Can type 1 diabetes mellitus turn into type 2 diabetes mellitus? Please explain upon what facts and medical principles the opinion is based. (2) Provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's diagnosed diabetes mellitus, whether type 1 or type 2, is caused by or otherwise related to the Veteran's period of active duty from January 1987 to January 1991, to include the treatment for service-connected IBD related symptoms, to include weight loss. Please state upon what facts and medical principles you base the opinion. (3) If the answer to Question 2 above is negative, is it at least as likely as not (a 50 percent probability or greater) that type I or 2 diabetes mellitus was caused by the Veteran's service-connected IBD or the medication, Prednisone, taken for the service-connected IBD? Please state upon what facts and medical principles you base the opinion. (4) If the answer to Question 3 is negative, is it at least as likely as not (a 50 percent probability or greater) that type I or II diabetes mellitus was aggravated by the Veteran's service-connected IBD or the medication, Prednisone, taken for the service-connected disability? Aggravation is different from causation in that it did not cause the disability but rather caused an increase in severity that is not due to the natural progress of the disability. Please state upon what facts and medical principles you base the opinion. (5) If the examiner finds that the service-connected IBD or the medication the Veteran takes for such disorder aggravates the 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 the diabetes mellitus prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. A full rationale, including reference to supporting clinical data and/or medical literature relating Prednisone and steroid use as directly or indirectly to diabetes, must be provided for all medical opinions given. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Sarah Campbell, 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.