Citation Nr: 21074047 Decision Date: 12/14/21 Archive Date: 12/14/21 DOCKET NO. 16-43 159 DATE: December 14, 2021 ORDER Entitlement to service connection for a neck disability is denied. Entitlement to service connection for a low back disability is denied. Entitlement to service connection for a right hip disability is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for a right knee disability is denied. REMANDED Entitlement to service connection for type II diabetes mellitus is remanded. Entitlement to service connection for left lower extremity peripheral neuropathy is remanded. Entitlement to service connection for right lower extremity peripheral neuropathy is remanded. FINDINGS OF FACT 1. The evidence fails to probatively establish that the Veteran's current neck disability is etiologically or presumptively related to his active duty service. 2. The evidence fails to probatively establish that the Veteran's current low back disability is etiologically or presumptively related to his active duty service. 3. The evidence fails to probatively establish that the Veteran's right hip disability is etiologically or presumptively related to his active duty service. 4. The evidence fails to probatively establish that the Veteran's current left knee disability is etiologically or presumptively related to his active duty service. 5. The evidence fails to probatively establish that the Veteran's current right knee disability is etiologically or presumptively related to his active duty service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a neck disability have not been met. 38 U.S.C. §§ 1110, 1112; 38 C.F.R. § 3.303, 3.307, 3.309. 2. The criteria for entitlement to service connection for a low back disability have not been met. 38 U.S.C. §§ 1110, 1112; 38 C.F.R. § 3.303, 3.307, 3.309. 3. The criteria for entitlement to service connection for a right hip disability have not been met. 38 U.S.C. §§ 1110, 1112; 38 C.F.R. § 3.303, 3.307, 3.309. 4. The criteria for entitlement to service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 1112; 38 C.F.R. § 3.303, 3.307, 3.309. 5. The criteria for entitlement to service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 1112; 38 C.F.R. § 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1974 to October 1974. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2015 rating decision issued by a Regional Office (RO) of the United States Department of Veterans Affairs (VA). In July 2019, the Veteran testified before the undersigned Veterans Law Judge at a Board videoconference hearing. Neither the Veteran nor his representative has raised any issues with the conduct of his Board hearing as to the duties discussed in Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); see also Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Thus, the Board need not discuss any potential issues in this regard. A copy of the hearing transcript has been associated with the electronic claims file. The claims being adjudicated below were previously before the Board in September 2019, where they were remanded for additional evidentiary development. These claims were remanded for the RO to undertake appropriate efforts to obtain updated VA treatment records, as well as private treatment records from Kaiser Permanente and Dr. J.E. Dugas. The claims were also remanded for the scheduling of VA examinations to assess whether the Veteran's claimed disabilities were etiologically related to a July 1974 in-service motor vehicle accident. In September 2019, the RO sent a notice letter to the Veteran requesting that he provide written authorization via VA Form 21-4142a allowing VA to obtain his private treatment records from Kaiser Permanente and Dr. J.E. Dugas. The Veteran did not respond to the RO's notice letter with the requested authorization. Instead, in September 2020, the Veteran submitted piecemeal records from Kaiser Permanente. As the RO appropriately requested the Veteran's cooperation in obtaining the outstanding complete private treatment records from Kaiser Permanente and Dr. J.E. Dugas, and the Veteran did not respond, VA's duty to assist obligations have been satisfied in this regard. The Veteran's updated VA treatment records have been associated with the electronic claims file. The requested VA examinations/medical opinions were obtained and are sufficient to fairly adjudicate the claims. The RO has substantially complied with the Board's previous remand directives as to the matters. See Stegall v. West, 11 Vet. App. 268 (1998). Under 38 U.S.C. § 7104, Board decisions must be based on the entire record, with consideration of all the evidence. The law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122, 128-29 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence within the period on appeal and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake, supra. Service Connection Service connection will be granted if it is shown that a veteran has a disability resulting from an injury or disease contracted in the line of duty, or for aggravation of a preexisting injury or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Generally, to establish service connection, a veteran must show: (1) a current disability; (2) an in-service incurrence of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred during service, the so-called "nexus" requirement. See 38 U.S.C. §§ 1110, 1131 (2018); 38 C.F.R. § 3.303 (2018); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). All elements must be satisfied before service connection may be achieved. Additionally, service connection may be achieved if any applicable presumptive service connection regulations apply to the Veteran's circumstances or when a claimed disability is shown to be proximately due to, the result of, or aggravated by a service-connected disability. 1. Entitlement to service connection for a neck disability is denied. 2. Entitlement to service connection for a low back disability is denied. 3. Entitlement to service connection for a right hip disability is denied. 4. Entitlement to service connection for a left knee disability is denied. 5. Entitlement to service connection for a right knee disability is denied. The Veteran has alleged that his current neck, low back, right hip, and bilateral knee disabilities were incurred during his active duty service. Specifically, he has alleged these disabilities are the result of an incident in September 1974 when he fell from a three story building. See July 2019 hearing testimony; January 2016 lay statement. Additionally, the Board has requested development as to whether these disabilities are the result of a July 1974 in-service motor vehicle accident. There is no allegation that any of these disabilities are secondary to any of the Veteran's service-connected disabilities under 38 C.F.R. § 3.310. The current disability element is not in dispute, as the record affirmatively establishes that the Veteran has been diagnosed with a neck, low back, right hip, and bilateral knee disability during the appellate period. See e.g. March 2020 VA examinations (diagnosing cervical disc displacement, lumbar disc displacement, status post right hip replacement, bilateral knee joint osteoarthritis and patellofemoral pain syndrome). In a February 1976 administrative decision, the RO determined that the Veteran's September 1974 fall from a third story window was the result of willful misconduct, as the incident was allegedly precipitated by excessive drinking. In a December 2020 VA medical opinion, a psychologist explained that this incident was not the result of willful misconduct; instead this accident and behavior were consistent with an undiagnosed and untreated bipolar disorder. As competent evidence has established that this in-service event was not the result of willful misconduct, but instead was an early manifestation of the Veteran's now service-connected bipolar disorder, the Veteran is no longer precluded from seeking service connection based on this in-service event. The Veteran has alleged that his neck, low back, right hip, and bilateral knee disabilities originated as a result of this September 1974 fall from a third story building. The Veteran's service treatment records confirm that this incident occurred; however, the records indicate that the Veteran landed on his feet. The records only document complaints of pain in both heels. A radiograph of the heels was negative for fractures and the Veteran was diagnosed with related soft tissue trauma. There is no indication from the service treatment records that this in-service fall resulted in any injury to the Veteran's neck, low back, right hip, or bilateral knees. It is expected that the service treatment records relevant to this in-service accident would document complaints and treatment for neck, low back, right hip, and bilateral knee injuries from a medical perspectivemuch like the injury to the heels if they were present and as severe as indicated by the Veteran in his lay statements proffered many years after the accident. See Fountain v. McDonald, 27 Vet. App. 258, 272-75 (2015). The absence of such expected evidence is probative in this determination. At the July 2019 Board hearing, the Veteran alleged that he was treated "for a week or so" at an intensive care facility following this accident. The Veteran did not indicate whether this alleged treatment was at a military or civilian provider. Contrary to the Veteran's allegations, the service treatment records indicate that the Veteran was seen at an outpatient clinic following the injury; he was hospitalized from September 9, 1974 to September 11, 1974, where he was diagnosed with soft tissue trauma and placed under observation; and he was further evaluated on September 11, 1974 at a military dispensary. The service treatment records documenting this in-service accident appear to be substantially complete. Despite the absence of corroborating evidence, the Veteran has alleged that his current neck, low back, right hip, and bilateral knee disabilities are related to this in-service fall. To date, no competent medical nexus has been obtained linking the Veteran's current neck, low back, right hip, and bilateral knee disabilities to his in-service September 1974 fall from a third story building. VA's obligation to obtain a medical opinion is only triggered when the record contains competent evidence establishing a current disability, an indication that the disability may be associated with service, and insufficient medical evidence to render a decision on the claim. See Daves v. Nicholson, 21 Vet. App. 46, 50-51 (2007) (citing McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006)). In this case, the sole indication that the Veteran's current neck, low back, right hip, and bilateral knee disabilities are related to his September 1974 fall from a third story building are the Veteran's own lay statements. See e.g., Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (since all veterans could make bare assertions that a service connected illness/injury caused their current medical problems, requiring examinations in such cases "would eliminate the carefully drafted statutory standards governing the provision of medical examinations and require the Secretary to provide such examinations as a matter of course in virtually every veteran's disability case."). As a lay person without medical training and expertise, the Veteran is not competent to render medical opinions concerning the etiology of medically complex orthopedic/musculoskeletal disabilities. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Thus, his lay opinion regarding the cause of his cited disabilities is not probative on the issue of medical nexus and is afforded no weight in this determination. Furthermore, the Board finds that the Appellant's bare assertion of a link between his current neck, low back, right hip, and bilateral knee disabilities and the September 1974 fall, without more, is insufficient to trigger VA's obligation to obtain a medical opinion under 38 U.S.C. § 5103A (d) in this case. As the record lacks any probative evidence establishing that the Veteran injured his neck, low back, right hip, and/or bilateral knees during the September 1974 fall accident, and there is no competent medical nexus evidence linking his current neck, low back, right hip, and/or bilateral knee disabilities to such an incident, the Veteran's claims for service connection based on this theory of entitlement must be denied. The Board has reviewed the Veteran's service treatment records for any diseases or injuries to the neck, low back, right hip, and bilateral knees, aside from the contention related to the September 1974 fall. A complete review of the Veteran's service treatment records show no indication of any right hip or right knee complaints, treatment, or diagnosis during the Veteran's active duty service. In March 1974, the Veteran complained of a 1-month history of low back pain, particularly when running. Physical examination showed pain in the right side of the low back, but good range of motion. The Veteran was assessed with a strain, and was recommended to use a heating pad as treatment. In July 1974, the Veteran was involved in a motor vehicle accident. Service treatment records indicate that a cervical spine radiograph was negative. Several days after the accident, the Veteran presented for a physical examination. He complained of "trauma to [the left] knee [and] [lumbosacral area] [complaining of] stiff neck [and] pain in [the left] knee." The Veteran was noted to being wearing a cervical collar, he had full range of motion (in the spine and left knee), no significant reflex deficits, and no spasms. His abrasions and contusions were healing. The records indicate that the Veteran's injuries were treated at a local emergency room and through referral to a civilian physician. The Veteran has not provided any information to identify or locate these private records, and thus, VA's duty to assist in obtaining such evidence has not been triggered. See 38 C.F.R. § 3.159(c)(1)(i). As noted above, the records related to the Veteran's September 1974 fall from a third story building only reference soft tissue injuries to the heels, without radiographic evidence of fracture. At the September 1974 exit examination, the neck, spine, musculoskeletal system, and lower extremities were listed as clinically normal. The corresponding Report of Medical History contained the Veteran's reports of experiencing swollen or painful joints (although the specific joints affected were not mentioned) and recurrent back pain. It was indicated that the Veteran had injured his neck in an auto accident (presumably the July 1974 motor vehicle accident) without sequelae. The Veteran's service treatment records establish in-service injuries to his neck, low back, and left knee, as discussed above. However, these injuries appeared to be acute and transitory as the affected body systems were deemed to be clinically normal at service discharge. There is no probative evidence of in-service injury or disease impacting the right hip or the right knee. Regarding the initial onset and continuity of his claimed disabilities, the Veteran has been an unreliable medical historian. At the July 2019 Board hearing, the Veteran testified that all of the disabilities being adjudicated began during his active duty service. As to his low back, the Veteran also told the November 2015 VA examiner that his low back symptoms began during service. Despite this, VA treatment records from August 2005 indicate that the Veteran had experienced chronic low back pain with "intermittent [symptoms] for 15 [years]," placing onset in approximately 1990. He told the March 2020 VA examiner that he first experienced chronic low back pain "around 40 years ago," placing onset in approximately 1980. In May 2008 VA treatment records, the Veteran reported onset of back pain "15 years ago when in prison." In September 2014 VA treatment records, the Veteran stated he "had a pain problem of one sort or another for 12 years" for neck, low back, or leg pain. Regarding the cervical spine, the Veteran reported to the March 2020 VA examiner that this condition "started around the early 2000s." The Veteran's VA treatment records also indicate his neck was injured in a 2017 car accident, where he suffered from whiplash. Private records from December 1993 noted "recurring upper and lower back and neck pain, started with industrial injury." The record shows that the Veteran worked for many years as a heavy equipment operator following service. Regarding his right hip, the Veteran told the March 2020 VA examiner that this condition "started around 10 years ago," placing initial onset in approximately 2010. At the November 2015 VA examination, the Veteran reported initial onset of knee symptoms in 1974, although the VA examiner questioned the validity of these reports, noting that the Veteran "acted vague about what he thought was the problem [with his knees]." In contradictory fashion, the Veteran reported to the March 2020 VA examiner that his left knee problems "started around 25 years ago," placing initial onset in approximately 1995. The above conflicting and inconsistent statements render the Veteran to be an unreliable medical historian, and his lay reported history regarding initial onset of his conditions in service and continuity of symptoms thereafter is not credible under the current evidentiary record. See Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995) (credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the testimony). Moreover, at the July 2019 Board hearing, the Veteran was not forthcoming regarding several post-service intercurrent injuries, as discussed above, regarding the neck and low back. For these reasons, the Veteran's lay reports regarding initial onset of his conditions in service and persistence of symptoms thereafter do not serve as probative evidence in this determination, and are entitled to no evidentiary weight. The Board now turns to the issue of medical nexus and the relevant VA examinations/medical opinions obtained in these matters. As previously determined by the Board in its September 2019 decision, the November 2015 VA medical opinion relating the Veteran's low back and bilateral knee disabilities to the in-service September 1974 fall rather than the July 1974 motor vehicle accident is not probative because it is wholly conclusory and unsupported by an adequate explanatory rationale. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Moreover, this opinion is based on an inaccurate factual premise, as there is no probative evidence establishing that the Veteran's low back or bilateral knees were injured in the September 1974 fall. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) ("An opinion based upon an inaccurate factual premise has no probative value."). In November 2016, a VA examiner opined that there was no nexus between the Veteran's July 1974 auto accident and his current neck pain. The VA examiner noted that there were normal radiographs of the cervical spine at the time of the accident and no in-service evidence to suggest that the injury was more than acute. Indeed, the VA examiner noted that the Veteran's cervical spine resolved without residuals during service, as noted by the normal clinical findings in the neck and spine at service discharge, and the note by the physician in the exit Report of Medical History, that any injury to the neck due to the auto accident had no sequelae. In the September 2019 Board decision, the Board remanded the claim for an additional VA examination to assess the Veteran's lay reports of continuity of neck pain over the years. A VA examination was conducted in March 2020, where the Veteran self-reported that his chronic cervical spine issues did not begin until the early 2000s, decades after his separation from service. The VA examiner noted the presence of abnormal range of motion of the cervical spine at the VA examination, but observed that the records showed no complaints or abnormal findings of the cervical spine as of at least a 2005 VA primary care visit. The examiner suggested the Veteran's lay reports of continuity since service were medically unfeasible, stating "if the claimant's injuries were persistent since [his in-service] motor vehicle accident, they would have definitely been noted or expressed." The VA examiner reiterated that the Veteran's cervical spine radiograph at the time of the accident was completely normal. Collectively, the Board finds the November 2016 and March 2020 VA medical opinions to be highly probative on the issue of whether the Veteran's current neck disability is etiologically related to the July 1974 motor vehicle accident. The March 2020 opinion corrected the evidentiary issues in the November 2016 opinion that were previously discussed in the September 2019 Board decision. The March 2020 VA examiner suggested that the Veteran's lay reports of continuity of symptoms since service were unsubstantiated by the record, which is consistent with the Board's factfinding, supra. The November 2016 VA examiner explained that the Veteran's cervical spine injury from the in-service motor vehicle accident was acute and resolved prior to service separation. Viewed in concert, the VA medical opinions are fully articulated and supported by a plausible rationale consistent with the available evidence of record. Following the receipt of these medical opinions, the Veteran submitted evidence showing recurring neck pain in 1993; however, this symptom was directly attributed to a post-service occupational injury entirely unrelated to the July 1974 motor vehicle accident. Accordingly, the available medical nexus evidence is adequate for evidentiary consideration and substantially weighs against the appeal. In March 2020, the Veteran presented for a VA examination of the back, knees, and right hip. In describing the medical history of the conditions, the Veteran placed initial onset for each condition after his separation from active duty service. Following a complete review of the electronic claims file and an in-person examination, the VA examiner determined that the Veteran's current low back, right hip, and bilateral knee disabilities were not etiologically related to the Veteran's July 1974 in-service motor vehicle accident. The VA examiner noted no significantly abnormal physical findings in the exam report documented a few days after the accident. The VA examiner explained that if the accident was severe enough to be the cause of the Veteran's present day issues, there would be a consistent and continuous pattern of care for chronic issues, which was not observed in the record. Indeed, the Veteran, himself, reported to the VA examiner that these conditions did not arise until well after his separation from service. Despite the evidence showing low back complaints in March 1974 and July 1974, and left knee complaints in July 1974, the relevant body systems were deemed to be clinically normal at the September 1974 service separation examination. There was no probative evidence establishing the Veteran's present disabilities until many years, even decades, after the Veteran's active duty service. A 1993 private record reported recurring low back pain, but this was attributed to a post-service workplace injury. Likewise, the Board has determined that the Veteran's reports of continuous symptoms since service lack credibility under the current evidentiary record. In adjudicating this appeal, the Board finds the March 2020 VA medical opinions to be highly probative, as they were supported by rational explanations and were based on an accurate assessment of the records and the Veteran's documented medical history. This negative medical nexus evidence weighs substantially against the Veteran's claims. In adjudicating these appeals, the Board has considered whether the Veteran can achieve service connection on a presumptive basis, as the Veteran's neck, low back, right hip, and bilateral knee disabilities are manifested by degenerative conditions, and arthritis is a chronic disease subject to presumptive service connection consideration under the provisions of 38 C.F.R. § 3.303(b), 3.307(a)(3), and 3.309(a). There is no probative evidence of record establishing that the Veteran experienced chronic radiograph-confirmed neck, low back, right hip, or bilateral knee arthritis in service or to a compensable degree within one year from service discharge. In fact, the September 1974 exit examination listed the neck, spine, and lower extremities as clinically normal. The record shows that these conditions did not develop until many years after the Veteran's separation from service, and the Veteran's lay reports regarding continuity of symptoms since service are contradicted by other lay and medical evidence to contrary and are not credible in this determination. Presumptive service connection is not warranted under the current record. In sum, there is no compelling evidence that the Veteran sustained any injury to his neck, low back, right hip, or bilateral knees during his September 1974 fall from a third story building. There is no evidence of right knee or right hip injuries or diseases during the Veteran's period of active duty service. While the Veteran injured his neck, back, and left knee in a July 1974 motor vehicle accident, the subsequent medical and lay evidence, including the probative VA medical opinions identified above, do not establish that the Veteran's current disabilities are in any way etiologically related to any in-service injuries, to include the July 1974 motor vehicle accident. Likewise, the evidence of record does not support the claims on a presumptive basis, as explained above. As the evidence preponderates against the claims, the benefit of the doubt rule has no application. Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990); 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Veteran's appeals seeking service connection for neck, low back, right hip, and bilateral knee disabilities must be denied. [Continued on Next Page] REASONS FOR REMAND 1. Entitlement to service connection for type II diabetes mellitus is remanded. The Veteran has alleged that his type II diabetes is the result of his in-service diet/food consumption, or in the alternative, it is secondary to his service-connected bipolar disorder, and the medication used to treat such a condition. A VA medical opinion obtained in March 2020 ruled out the possibility that the Veteran's current type II diabetes mellitus was etiologically related to diet/food consumption during the Veteran's period of active duty service, and no further evidentiary development is warranted regarding this theory of entitlement. A VA medical opinion was obtained in March 2020 to assess whether the Veteran's type II diabetes mellitus was secondary to the Veteran's bipolar disorder and related medication under 38 C.F.R. § 3.310. The VA examiner explained that the Veteran's bipolar disorder and related medications were not medically known to predispose the Veteran to type II diabetes. The VA examiner was unable to determine the baseline for the Veteran's type II diabetes mellitus, but nevertheless provided the same rationale regarding causation as also supporting no aggravation. This is an unacceptable explanation, as the VA examiner did not explain whether the Veteran's type II diabetes mellitus underwent any incremental increase in disability (any additional impairment of earning capacity) regardless of permanence due to the Veteran's service-connected bipolar disorder and related medication. See Ward v. Wilkie, 31 Vet. App. 233, 239 (2019). The record contains abundant evidence regarding the Veteran's hemoglobin A1C level over time, and the VA examiner did not engage in any analysis as to whether such findings were consistent with the normal progression of type II diabetes mellitus or were otherwise indicative of some aggravating factor that could be related to the Veteran's service-connected bipolar disorder. Given these considerations, the Board finds the claim must be remanded for an addendum VA medical opinion that appropriately considers the aggravation prong of a secondary service connection claim. Additionally, the March 2020 VA examiner opined that the Veteran's type II diabetes mellitus was caused by factors such as being sedentary, physical inactivity, and smoking cigarettes. In an October 2021 appellate brief, the Veteran's attorney raised the prospect that the Veteran's bipolar disorder resulted in poor lifestyle choices that could have greatly contributed to the development of type II diabetes mellitus. The representative cited medical literature indicating that type II diabetes mellitus is more common in patients with bipolar disorder than the general population. Upon remand, the RO is requested to obtain an addendum VA medical opinion addressing this theory of entitlement. The RO is requested to obtain updated VA treatment records from August 2020 to the present, if such evidence exists. 38 C.F.R. § 3.159(c)(2) and (3). 2. Entitlement to service connection for left lower extremity peripheral neuropathy is remanded. 3. Entitlement to service connection for right lower extremity peripheral neuropathy is remanded. The March 2020 VA medical opinions clearly indicate that the Veteran's bilateral lower extremity neuropathy is causally related to the Veteran's type II diabetes mellitus. As the issue of entitlement to service connection for type II diabetes is unresolved, these matters are remanded as inextricably intertwined with that pending claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (determining that issues are inextricably intertwined when a decision on one issue would have a "significant impact" on a claim for the second issue). The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from August 2020 to the present, if such evidence exists. 2. Obtain an addendum opinion from an appropriate VA examiner regarding the outstanding medical questions related to the Veteran's type II diabetes mellitus. Following a complete review of the electronic claims file, including a copy of this REMAND, the VA examiner is requested to address the following inquiries: (a.) Is it at least as likely as not (50 percent probability or greater) that the Veteran's current type II diabetes mellitus underwent any incremental increase in disability, regardless of its permanence due to the Veteran's service-connected bipolar disorder and related treating medications? In answering this question, the VA examiner is requested to consider the Veteran's hemoglobin A1C level over time and opine on whether such findings are consistent with the normal progression of type II diabetes mellitus or are otherwise indicative of some aggravating factor, to possibly include the Veteran's service-connected bipolar disorder and related treating medications. (b.) Is it at least as likely as not (50 percent probability or greater) that the Veteran's service-connected bipolar disorder resulted in any risky lifestyle choices that were a substantial factor in the Veteran's development of type II diabetes mellitus? (i) If so, is it at least as likely as not (50 percent probability or greater) that the Veteran's type II diabetes mellitus would not have occurred but for the risky lifestyle choices caused by the Veteran's service-connected bipolar disorder? The VA examiner is requested to review and discuss the medical literature cited in the October 2021 appellate brief. 3. The RO is requested to ensure that all medical opinions issued by the VA examiners are accompanied by complete rationales based on each examiner's clinical experience and medical expertise; established medical principles; and/or citations to the electronic claims file, as appropriate. Cynthia M. Bruce Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Galante, 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.