Citation Nr: 21067483 Decision Date: 11/04/21 Archive Date: 11/04/21 DOCKET NO. 20-15 102A DATE: November 4, 2021 REMANDED Entitlement to service connection for type II diabetes mellitus, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for peripheral neuropathy, to include as secondary to type II diabetes mellitus, is remanded. REASONS FOR REMAND The Veteran had active service in the United States Navy from July 1975 to July 1979 and in the United States Army from March 1984 to March 1987. He had additional service in the Missouri Air National Guard, which included a period of active duty from April 2003 to March 2004. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2018 rating decision. In October 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. Upon review, the Board finds that additional development is needed prior to adjudication of the issues on appeal. During the October 2021 hearing, the Veteran asserted that he developed diabetes mellitus as a result of weight gain from medications prescribed for his service-connected PTSD. The Board notes that obesity cannot qualify as a disease or injury or as an in-service event to warrant service connection; however, obesity can be considered as an intermediate step between a service-connected disability and a current disability that may be service-connected under a secondary basis under 38 C.F.R. § 3.310. See Marcelino v. Shulkin, 29 Vet. App. 155 (2018); VAOPGCPREC 1-2017 (Jan. 6, 2017); Walsh v. Wilkie, 32 Vet. App. 300 (2020). However, the evidence of record does not include a medical opinion addressing this theory of entitlement. Therefore, the Board finds that a VA medical opinion is needed to determine the etiology of the Veteran's diabetes mellitus. The Veteran has also claimed that his peripheral neuropathy is secondary to his diabetes mellitus. Therefore, his claim for service connection for peripheral neuropathy is inextricably intertwined with his claim for service connection for diabetes mellitus. See Gurley v. Peake, 528 F.3d 1322 (Fed. Cir. 2008) (remand of inextricably intertwined claims was warranted for reasons of judicial economy even in absence of administrative error); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two or more issues are inextricably intertwined if one claim could have significant impact on the other). The matters are REMANDED for the following action: 1. The agency of original jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all healthcare providers who have provided treatment for diabetes mellitus and peripheral neuropathy. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA treatment records. 2. After completing the foregoing development, the AOJ should refer the Veteran's claims file to a suitably qualified VA examiner for a medical opinion regarding the etiology of the Veteran's diabetes mellitus. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran's diabetes mellitus is causally or etiologically related to his active service, to include his service in Saudi Arabia during the period from April 2003 to March 2004. The examiner should also opine as to whether it is at least as likely as not that the Veteran's diabetes mellitus was either caused by or aggravated by his service-connected PTSD, to include any medications used to treat the disorder. In rendering this opinion, the VA examiner should opine as to (1) whether the Veteran's service-connected PTSD, including the medications used to treat that disability, caused aggravated the Veteran's weight gain and obesity; (2) if so, whether the causation or aggravation of obesity as a result of service-connected disability was a substantial factor in causing diabetes mellitus; and (3) whether the diabetes mellitus would have occurred but for obesity caused or aggravated by the service-connected PTSD. In rendering these opinions, the examiner should specifically consider the medical literature submitted by the Veteran in support of his claim in October 2021. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. After completing the foregoing development, the AOJ should refer the Veteran's claims file to a suitably qualified VA examiner for a medical opinion regarding nature and etiology of the Veteran's peripheral neuropathy. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran's peripheral neuropathy is causally or etiologically related to his military service. The examiner should also opine as to whether it is at least as likely as not that the Veteran's peripheral neuropathy was either caused by or aggravated by his diabetes mellitus. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. The AOJ should conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Osegueda, 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.