Citation Nr: A21020045 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 200114-63286 DATE: December 15, 2021 REMANDED Entitlement to service connection for diabetes mellitus is remanded. Entitlement to service connection for limitation of motion of the arm (right shoulder osteoarthritis with rotator cuff tendinopathy (now claimed as right shoulder condition)) is remanded. Entitlement to service connection for limitation of motion of the arm (left shoulder osteoarthritis with rotator cuff tendinopathy (now claimed as left shoulder condition)) is remanded. Entitlement to service connection for hypertrophic gastritis (secondary to medications and to include as secondary to contaminated water) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1980 to April 1982. The matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2018 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The rating decision on appeal was issued in April 2018 and constitutes an initial decision; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies. In the March 2019 VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the agency of original jurisdiction (AOJ) decision on appeal. 38 C.F.R. § 20.301. As a preliminary matter, the Board notes that the issue of service connection for stress and anxiety with major depression was later recharacterized as major depressive disorder and granted service connection effective March 2, 2018. In a rating decision issued subsequent to the submission of the March 2019 VA Form 10182. As the issue is considered fully resolved, the Board does not have any jurisdiction to adjudicate this claim. 1. Service Connection Diabetes Mellitus The Veteran seeks service connection diabetes mellitus to include as secondary to stress and anxiety, as stated in the March 2018 VA 21-526EZ form. The Veteran currently has diabetes mellitus. In the March 2018 VA medical treatment record, the Veteran was observed to be following diabetes mellitus regimen. The Veteran is also currently service connected for major depressive disorder. The claims file is devoid of VA examination and opinion showing whether the service-connected major depressive disorder proximately causes or otherwise aggravates the Veteran's diabetes mellitus. The Board concludes that the failure to obtain an adequate VA etiology opinion is a pre-decisional duty to assist error. For this reason, the Board remands the Veteran's claim in order to obtain an adequate VA examination, with all applicable diagnoses during any period on appeal identified and with all appropriate etiological opinions. 2. Service Connection Right and Left Shoulders Based on the Veteran's claim of service connection for bilateral shoulder conditions, the RO provided the Veteran with a VA examination in March 2018 and provided a negative nexus opinion, explaining that the Veteran's left finger condition does not affect the shoulder joints bilaterally as they are proximal with different tasks. However, the examiner did not opine on whether the finger condition could aggravate the Veteran's bilateral shoulder conditions. The Board concludes that the failure to obtain an adequate VA etiology opinion is a pre-decisional duty to assist error. For this reason, the Board remands the Veteran's claim in order to obtain an adequate VA examination, with all applicable diagnoses during any period on appeal identified and with all appropriate etiological opinions. 3. Service Connection Hypertrophic Gastritis The April 2018 rating decision denied the claim based on lack of in-service event and as secondary to medication. The Veteran currently has a diagnosis of gastritis as supported by March 2018 VA treatment record. Service treatment records note several complaints of stomach pains. For example, in November 1981, the Veteran complained of throwing up and having chest pain. In the February 1982 report of medical history, while the Veteran denied frequent indigestion, he did report to stomach, liver, or intestinal troubles. There is currently no VA examination on file to determine the nature and etiology of the claimed gastritis. The Board concludes that the failure to obtain an adequate VA etiology opinion is a pre-decisional duty to assist error. For this reason, the Board remands the Veteran's claim in order to obtain an adequate VA examination, with all applicable diagnoses during any period on appeal identified and with all appropriate etiological opinions. The matters are REMANDED for the following action: 1. Schedule VA examinations to determine the etiology of his claimed diabetes mellitus. The record, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Any indicated evaluations, studies, and tests should be conducted. The need for further physical examination is left to the discretion of the examiner. The examiner should respond to the following questions: (A) For the diagnosed diabetes mellitus, it is as at least as likely as not (a 50 percent or greater probability) that diabetes mellitus was incurred in, or is otherwise related, to the Veteran's active service? (B) Is it as at least as likely as not (a 50 percent or greater probability) that diabetes mellitus was proximately caused by or aggravated by the Veteran's service-connected major depressive disorder? A rationale should be provided for any opinion offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must 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), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinion must support the conclusions reached with an analysis that is adequate to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 2. Provide the claims file, to include a copy of this remand, to an appropriate medical professional for an addendum opinion as to the claimed diabetes mellitus. The need for another in-person examination is left to the discretion of the medical professional offering the addendum opinion. The examiner should respond to the following question: Is it as at least as likely as not (a 50 percent or greater probability) that bilateral shoulder conditions were proximately caused by or aggravated by the Veteran's service-connected finger condition of the left hand? A rationale should be provided for any opinion offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must 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), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinion must support the conclusions reached with an analysis that is adequate to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. Schedule VA examinations to determine the etiology of his claimed gastritis. The record, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Any indicated evaluations, studies, and tests should be conducted. The need for further physical examination is left to the discretion of the examiner. The examiner should respond to the following questions: (A) For any diagnosed gastritis, it is as at least as likely as not (a 50 percent or greater probability) that gastritis was incurred in, or is otherwise related, to the Veteran's active service, to include medications taken or to any polluted water while in service? The examiner is specifically directed to the November 1981 report of chest pain as well as the February 1982 report of medical history where the Veteran complained of having had stomach pains. A rationale should be provided for any opinion offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must 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), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinion must support the conclusions reached with an analysis that is adequate to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. Mariah N. Sim Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.J. Kim 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.