Citation Nr: 21071583 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 17-46 962 DATE: November 30, 2021 REMANDED Service connection for diabetes mellitus type 2 (DM2), to include as secondary to service-connected coronary artery disease (CAD) and/or service-connected hypertension (HTN), is remanded. REASONS FOR REMAND The Veteran had active duty in the United States Army from October 1982 to November 1986. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In August 2021, the Veteran and his spouse testified at a Board hearing before the undersigned Veterans Law Judge. The Veteran's claims file contains a copy of the hearing transcript. Discussion Regrettably, a remand is necessary in this case to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C. § 5103; 38 C.F.R. § 3.159. The Veteran asserts that DM2 was proximately caused by or aggravated by service-connected CAD and/or service-connected HTN. In an August 2015 letter, a private physician noted ongoing treatment for hypertension, hyperlipidemia, CAD, and diabetes "with heart problems due to hypertension." Although noting concurrent treatment, there was no opinion on whether diabetes was caused or aggravated by CAD or hypertension. In several treatment records dated from 2013 to 2017, the Veteran's private cardiologist noted diagnosis of CAD and in a section labelled "treatment plan" noted "dysmetabolic syndrome without further explanation. In an October 2019 letter, the Veteran's private cardiologist noted that the Veteran had chest pain on minimum exertion with decreased energy, fatigue, and shortness of breath. There was no comment regarding diabetes or weight gain. In August 2017, the Veteran underwent VA heart and diabetes examinations. A physician's assistant reviewed the history and current symptoms of both disorders. The clinician explained the history and separated mechanisms of the diseases and noted a review of the November 2015 private opinion. The examiner found that diabetes was not directly caused by active duty service. Contrary to the Veteran's report of an onset of the disease in service, the examiner was unable to find evidence to support an onset in service or until the August 2015 physician's report. The examiner explained the physiology of diabetes, CAD and hypertension but did not provide a clear and comprehensive opinion other than a conclusive sentence that diabetes was not aggravated by hypertension. At the August 20, 2021 Board hearing, the Veteran's spouse, an intensive care (ICU) nurse, testified that, it is her professional opinion that the causal relationship between the Veteran's DM2 and service-connected CAD and/or service-connected HTN emanates from, [M]etabolic syndrome [has] risk factors of a cardiac disease. So, what [the Veteran] has with his HTN {...] not being controlled, which led to [...] the narrowing of the blood vessels with his heart, [and] caused damage to his heart. So, [...] [the] risk factors [including high cholesterol and insulin resistance] [come] from excessive inactivity. Dr. H. [the Veteran's private physician] explained that even [upon] minimal exertion, [the Veteran] has chest pains [to the extent that the Veteran can no longer work]. [As such,] he [was] no longer able to move around as much, which [led] to excessive weight gain. [And] excessive weight gain [caused] him to [become] insulin resistant. So, I believe [that is] why these risk factors [presumably metabolic syndrome explains why DM2 emanated or has a causal relationship with service-connected CAD and/or service-connected HTN]. See August 20, 2021 Hearing Transcript, pp. 5-6. A nurse's observations constitute competent medical evidence. See YT v. Brown, 9 Vet. App. 195, 201 (1996); see also Goss v. Brown, 9 Vet. App. 109 (1996). None of the private physician's or VA physician's assistant provided an explanation metabolic syndrome and its role in causation, aggravation, and/or connexity between these disabilities. The weight of competent evidence shows that the Veteran has these comorbid disorders, but the VA examiner did not provide a comprehensive, and hence, adequate examination. The competent observation of the Veteran's nurse-spouse has triggered VA's duty to assist. Consequently, an addendum opinion is necessary to ensure that VA conforms to its duty to assist. The matters are REMANDED for the following actions: 1. Contact the Veteran and his representative to ascertain whether there are outstanding private records related to the three disabilities articulated above. If affirmatively indicated, prepare releases, obtain the records, and associate the records with the claims file. The RO must make two attempts to obtain these relevant records unless the first attempt demonstrates that further attempts would be futile. Should VA not obtain any private records (as indicated), the RO must (1) inform the Veteran of the unobtained records (2) tell the Veteran steps taken to obtain them, and (3) tell the Veteran that the claim will be adjudicated without the records. See 38 U.S.C. § 5103A(b)(2)(B). 2. Obtain any and all outstanding VA treatment records, progress notes and associate the records with the claims file. 3. Arrange for an VA addendum with an appropriate clinician. The clinician must review the entirety of the claims file and indicate such review in the body of the addendum. The clinician must address the competent assertions of the Veteran's spouse concerning metabolic syndrome and the theory that the cardiovascular diseases caused inactivity contributing to weight gain which caused or aggravated diabetes. Upon completion of the above, the clinician should respond to the following inquiries: a. Whether it is at least as likely as not (50 percent of more) that the Veteran's DM2 had its onset in service or is otherwise etiologically related to the Veteran's active-duty service, including any incidence of service AND b. Whether it is at least as likely as not that service-connected CAD and/or service-connected HTN proximately caused, or aggravated, DM2. The Veteran is competent to report his symptoms and history. Such reports, including those of continuity of symptomatology and functional limitations, must be acknowledged and considered in formulating any opinion. If the clinician rejects the Veteran's reports, the clinician must provide an explanation for such rejection. Complete, clearly stated rationales for the conclusions reached must be provided. Merely stating that it is the clinician's opinion that a disorder was not caused or aggravated by a service does not suffice. An explanation takes into account the record and pertinent medical principles and the rationale should include citation to pertinent evidence and/or medical principles which form the opinion. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. J. Komins, 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.