Citation Nr: 21072307 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 15-14 497 DATE: December 2, 2021 REMANDED Entitlement to service connection for type 1 diabetes is remanded. Entitlement to service connection for loss of pancreatic function, to include as secondary to diabetes, is remanded. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to diabetes, is remanded. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to diabetes, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1996 to January 1997 and October 2003 to February 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned in June 2018. This matter was previously remanded by the Board in October 2018 and May 2021. The case has been returned to the Board at this time for further appellate review. 1. Entitlement to service connection for type 1 diabetes is remanded. This matter was remanded in May 2021 to obtain a VA medical opinion from an endocrinologist, or other appropriate medical specialist, with respect to the Veteran's service connection claim for diabetes. In this regard, the VA examiner was directed to discuss the Veteran's December 2008 VA treatment record which notes that the Veteran's anthrax vaccine is a suspected trigger for his diabetes and a July 2018 private medical opinion. A VA opinion was obtained in June 2021 from an endocrinologist. The VA examiner opined that it is less likely than not that the veteran developed diabetes as a result of his military service, however, in providing a rationale, the VA examiner did not address the Veteran's December 2008 VA treatment record or the July 2018 private medical opinion. In addition, the VA examiner was directed to opine whether it is at least as likely as not that the Veteran's type 1 diabetes had its onset in and/or is otherwise etiologically related to his active service. The VA examiner noted that they reviewed the evidence of record and found no evidence of diabetes while the Veteran was on active duty or that it occurred within the first year after discharge, however, the Board finds that this statement does not adequately provide a clear opinion as to whether the Veteran's diabetes is otherwise etiologically related to his active service, particularly given that the Veteran was diagnosed within two years of leaving active duty service and has indicated that he believes he was manifesting symptoms of diabetes within a year of leaving active duty service. Accordingly, remand for a new VA opinion is necessary to ensure compliance with the Board's prior remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The Board also notes that the Veteran's representative has now raised the argument that the Veteran's high blood pressure in service is related to his diagnosis of diabetes, as diabetes and hypertension frequently occur together and there is a substantial overlap between the etiology and disease mechanisms of diabetes and hypertension. 2. Entitlement to service connection for loss of pancreatic function, to include as secondary to diabetes, is remanded. 3. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to diabetes, is remanded. 4. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to diabetes, is remanded. The Veteran asserts that he has loss of pancreatic function and peripheral neuropathy of the bilateral lower extremities due to his diabetes. As the outcome of the Veteran's service connection claims for loss of pancreatic function and peripheral neuropathy of the bilateral lower extremities are dependent on whether service connection is established for diabetes, these claims are inextricably intertwined, and thus are also remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any appellate review on the other claim meaningless and a waste of judicial resources, the two claims are inextricably intertwined). The matters are REMANDED for the following action: Obtain an opinion with an endocrinologist, or other appropriate medical specialist, who has not previously opined about the Veteran's claim, to determine the nature and etiology of the Veteran's type 1 diabetes. If the selected clinician determines that an examination is necessary to respond to this request, such examination should be scheduled. Following review of the claims file, and examination of the Veteran if deemed necessary, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's type 1 diabetes had its onset in and/or is otherwise etiologically related to his active service, including but not limited to his in-service anthrax vaccine, or manifested within one year of service. The medical specialist must discuss the (1) Veteran's December 2008 VA treatment record which notes that the Veteran's anthrax vaccine is a suspected trigger for his diabetes, (2) July 2018 private medical opinion stating that the Veteran's diabetes was auto-immune and an auto-immune trigger was possibly by Anthrax vaccine, (3) October 1999 physician's testimony before Congress, and (4) July 2002 and December 2004 medical articles written by Dr. Nass and submitted by the Veteran. The VA examiner is also asked to discuss, in detail, whether the Veteran's in-service (1) high blood pressure and (2) numbness and tingling of his hands and feet were symptoms of the Veteran's diabetes. (Continued on the next page) The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide a reason for doing so; however, the Veteran's history of symptoms capable of lay observation cannot be dismissed solely on the basis that they are not recorded in contemporaneous treatment records. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If an opinion cannot be given without resorting to speculation, the medical specialist should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the medical specialist (does not have the knowledge or training). M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Elias, Associate 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.