Citation Nr: 21006388 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 17-19 015 DATE: February 4, 2021 REMANDED Entitlement to a disability rating in excess of 20 percent for right eye diabetic retinopathy with fluctuating vision and blurred vision associated with type II diabetes mellitus prior to July 1, 2019 is remanded. Entitlement to a compensable disability rating for right eye diabetic retinopathy with fluctuating vision and blurred vision associated with type II diabetes mellitus from July 1, 2019 is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from July 1962 until his honorable discharge in September 1966. The Veteran also served in the United States Army from July 1975 until his honorable discharge in July 1978. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision by the Indianapolis, Indiana Regional Office (RO) of the United States Department of Veterans Affairs (VA). In December 2019, the Veteran testified at a videoconference Board hearing before the undersigned Veterans Law Judge (VLJ), sitting at the RO in Chicago, Illinois. A transcript of the hearing has been associated with the record on appeal. During the hearing, the undersigned held the record open for 90 days to allow for the submission of additional evidence. In April 2020, the Board remanded the case to the RO for further development. Specifically, the Board directed the RO to obtain an updated VA examination and to notify the Veteran that the last page of his July 2019 Disability Benefits Questionnaire (DBQ) is missing from the claims file and to provide him an opportunity to re-submit the July 2019 DBQ. In response, in April 2020, the RO sent the Veteran a supplemental development letter to notify the Veteran that the last page of his July 2019 DBQ is missing from the claims file and to provide him an opportunity to re-submit the July 2019 DBQ; and in September and November 2020, the RO obtained a VA eye examination and an addendum opinion. The Board notes that in May 2020, the Veteran submitted the complete July 2019 DBQ. The Board finds that there has been substantial compliance with the Board’s previous remand directives regarding the issue(s) on appeal. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to a disability rating in excess of 20 percent for right eye diabetic retinopathy with fluctuating vision and blurred vision associated with type II diabetes mellitus prior to July 1, 2019 is remanded. 2. Entitlement to a compensable disability rating for right eye diabetic retinopathy with fluctuating vision and blurred vision associated with type II diabetes mellitus from July 1, 2019 is remanded. Due to the similar dispositions for the above claims on appeal, the Board will address them in a common discussion below. Where VA provides the veteran with an examination, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Subsequent to the April 2020 Board remand, the Veteran was afforded a VA examination in September 2020 with an addendum opinion in November 2020, by the same author. The September 2020 VA examiner found that the Veteran did not have diabetic retinopathy, nor any other eye condition (other than congenital or developmental errors of refraction) and noted that the Veteran has bilateral postoperative cataracts with replacement intraocular lenses without incapacitating episodes. The September 2020 VA examiner explained that the Veteran’s cataracts are not related to the Veteran’s service-connected type II diabetes mellitus and that the Veteran no longer has retinopathy. However, the VA examiner did not provide an opinion if the Veteran’s cataracts were caused by or aggravated by his diabetic retinopathy that is documented during the period on appeal but rather simply noted that there was no retinopathy on the present examination. The RO requested a supplemental opinion to address inconsistencies in the September 2020 VA examination. Specifically, (1) to identify all other eye conditions that the Veteran has, or has had during the period on appeal; and (2) for each condition, the examiner should opine if the condition is a continuation of or is caused by the Veteran’s service-connected diabetic neuropathy or his service connected diabetes. The November 2020 supplemental opinion noted that the Veteran is a poor historian and was pseudophakic with no diplopia, retinopathy, nor glaucoma found on the September 2020 VA examination. The VA examiner was also asked to note the February 2020 VA treatment records reflecting that the Veteran began experiencing diplopia; the October 2017 VA examination that diagnosed the Veteran with bilateral non-proliferative diabetic retinopathy, bilateral ptosis, and bilateral pseudophakia with secondary cataract/posterior capsule opacification on the right; and the July 2019 private provider Disability Benefits Questionnaire. In response, the VA examiner simply noted that there was no diplopia, glaucoma, ptosis, capsular opacification, or retinopathy/maculopathy on the current VA examination and noted that the Veteran was pseudophakic. However, despite the fact that the September 2020 VA examiner noted that the Veteran did not currently have diabetic retinopathy, the record indicates that he has had diabetic retinopathy during the period on appeal and the September 2020 VA examiner failed to opine if the Veteran’s diabetic retinopathy (during the period on appeal) caused or aggravated his other eye disabilities during the period on appeal. For the above reasons, remand is required. The Board notes that despite most of the Veteran’s eye disabilities not being found on the most recent VA examination, this does not negate the fact that he was diagnosed with the disabilities during the period. The VA examiner failed to offer an opinion to address the causation of the Veteran’s visual disabilities beyond opining that the Veteran no longer has diabetic retinopathy. The Board notes that the Veteran submitted a July 2019 DBQ for eye conditions completed by a private provider. The private provider diagnosed the Veteran with open angle glaucoma and diabetic retinopathy; corrected distance visual acuity of 20/40 or better and a visual field defect due to a Humphreys 24-2 threshold. The private provider also noted that the Veteran had ptosis, glaucoma, retinal conditions, neurologic eye conditions, bilateral postoperative cataracts with replacement intraocular lenses. The private provider noted multiple causes of the Veteran’s decrease in visual acuity, including due to the bilateral glaucoma diagnosis. Because the private provider does not distinguish the impairment caused by the Veteran’s service-connected disabilities alone, it is not adequate. Furthermore, the Board notes that the private provider did not address causation or aggravation for the Veteran’s non-service-connected eye disabilities. Therefore, a VA addendum opinion should be obtained. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s eye disabilities (any eye disability that has been present during the period on appeal other than diabetic retinopathy of the right eye) is at least as likely as not (50 percent probability or greater) related to, proximately due to, or aggravated beyond its natural progression due to his service-connected diabetic retinopathy of the right eye, type II diabetes, peripheral neuropathy, and/or peripheral vascular disease. The examiner is advised that any disability during the period on appeal, even if resolved prior to the examination, is a current disability for VA purposes. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire must be utilized. JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Deemer, 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.