Citation Nr: 21076441 Decision Date: 12/23/21 Archive Date: 12/23/21 DOCKET NO. 13-89 494A DATE: December 23, 2021 REMANDED Entitlement to service connection for diabetes mellitus type II, is remanded. Entitlement to service connection for a heart disorder, to include as secondary to diabetes mellitus, is remanded. Entitlement to service connection for an eye disorder, to include as secondary to a heart disorder and/or diabetes mellitus, is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1958 to April 1960, with additional periods of service in the Army National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). This case has been before the Board several times, and was most recently before the Board in May 2021, at which time it was remanded for further development, as discussed below. The Board finds that the remand directives were not substantially complied with and thus another remand is warranted. Stegall v. West, 11 Vet. App. 268, 271 (1998). The May 2021 Board decision also remanded the claim of service connection for a right knee disorder, and a November 2021 rating decision subsequently granted service connection for degenerative arthritis of the right knee. 11/01/2021, Rating Decision. As such, the right knee issue is no longer before the Board. 1. Entitlement to service connection for diabetes mellitus type II, is remanded. A May 2021 Board decision found the January 2020 and November 2020 VA examinations to be incomplete for having failed to provide supporting rationale for the conclusions reached. Specifically, the January 2020 VA examiner merely stated that there was insufficient evidence to determine whether diabetes mellitus was etiologically related to service and to determine whether it was aggravated beyond its natural progression. The November 2020 examiner opined that the diabetes mellitus type II was not etiologically related to active service without a supporting rationale. Both VA examiners relied largely on the lack of documented treatment of diabetes in the service treatment records. The Board remanded the claim and directed the Agency of Original Jurisdiction (AOJ), in relevant part, to schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran's diabetes mellitus type II. The examiner was directed to provide opinions as to whether it is clear and unmistakable that diabetes mellitus type II pre-existed active service. And, if so, whether it is clear and unmistakable that the pre-existing diabetes mellitus type II was not aggravated during service, or whether it is clear and unmistakable that any increase in service was due to the natural progress. And, if diabetes mellitus type II did not pre-exist service, whether it is clear and unmistakable that any increase in service was due to the natural progress. 05/20/2021, BVA Decision. Subsequently, an August 2021 VA examiner opined that it is clear and unmistakable that the Veteran's diabetes mellitus type II pre-existed service based on the Veteran's account that he was diagnosed at age 14 through Indian Health, which is corroborated by the American Diabetes Mellitus Association regarding high prevalence of diabetes mellitus type II within Native American populations. However, the examiner did not provide a clear opinion as to whether it is clear and unmistakable that the pre-existing diabetes mellitus type II WAS NOT aggravated during service. In support, the examiner remarked on the lack of documented treatment of diabetes in the service treatment records but did not explicitly consider the Veteran's statements indicating that he experienced symptoms of diabetes during active service, to include difficulty urinating. Moreover, the examiner's rationale supporting the negative opinion addressed whether it is clear and unmistakable that the pre-existing diabetes mellitus type II WAS aggravated during service, which is the incorrect standard and did not comply with the Remand directives. 08/17/2021, C&P Exam; 08/17/2021, C&P Exam (medical opinion). As such, the Board finds that the remand directives were not substantially complied with and, therefore, another remand is warranted. Stegall, 11 Vet. App. at 271. 2. Entitlement to service connection for a heart disorder, to include as secondary to diabetes mellitus, is remanded. 3. Entitlement to service connection for an eye disorder, to include as secondary to a heart disorder and/or diabetes mellitus, is remanded. The Board finds that the Veteran's claims of entitlement to service connection for a heart disorder and an eye disorder are inextricably intertwined with the claim of entitlement to service connection for diabetes mellitus type II and will defer consideration of these matters. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (stating that two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). As described in the Board's 2019 remand, the Veteran was afforded VA heart and eye examinations in June 2019 and May 2019, respectively. The heart examiner found the Veteran's coronary artery disease was related to DMII. The eye examiner found diabetic retinopathy was related to DMII. As such, adjudication of these two matters is deferred until the above development is completed. These matters are REMANDED for the following actions: 1. Obtain any outstanding VA treatment records. Additionally, request the Veteran to submit any relevant private treatment reports or provide VA with authorization to obtain any such records. 2. After completing directive #1, obtain an addendum opinion by an appropriate clinician regarding nature and etiology of diabetes mellitus type II. An in-person examination is not required unless deemed necessary by the clinician. The clinician should review the virtual file, including a copy of this Remand. The examiner is to address: (a.) Whether diabetes mellitus type II clearly and unmistakably (i.e., undebatably) existed prior to his active service. If so, whether the disability clearly and unmistakably was NOT aggravated (increased in severity beyond the natural progression) in service beyond its natural progression. Please explain why, to include references to relevant evidence. (b.) If the examiner finds that diabetes mellitus type II EITHER did not clearly and unmistakably pre-exist service, OR was not clearly and unmistakably aggravated by service, then the examiner must opine whether it is at least as likely as not related to service. (c.) If aggravation is found, please state, to the extent possible, the baseline level of disability prior to aggravation. Consider all lay and medical evidence, to include in-service treatment, post-service treatment, and the Veteran's contentions at the April 2014 hearing. See 04/22/2014, Hearing Testimony (stating that the Veteran experienced symptoms during active service, to include difficulty urinating and cold sweats). Consider the findings of the August 2021 VA examination, to include the opinion that the Veteran's diabetes mellitus type II pre-existed service. A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner 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 examiner (does not have the knowledge or training). If any medical literature is cited, then provide a copy of it or a link to it. Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board David Han 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.