Citation Nr: 21007523 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 18-20 639 DATE: February 9, 2021 ORDER Service connection for Type II diabetes mellitus is granted. REMANDED Entitlement to service connection for a recurrent lumbosacral spine disability, to include lumbar strain and radiculopathy, is remanded. Entitlement to service connection for a recurrent right shoulder disability is remanded. Entitlement to service connection for bilateral hearing loss is remanded. FINDING OF FACT Diabetes mellitus originated during active service. CONCLUSION OF LAW The criteria for service connection for diabetes mellitus have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.102. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from April 1981 to March 1986. The Veteran appeared at a February 2020 videoconference hearing before the undersigned Acting Veterans Law Judge. The hearing transcript is of record. Service Connection for Diabetes Mellitus Service connection may be granted for recurrent disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The service treatment records state that the Veteran was diagnosed with gestational diabetes mellitus. A February 2020 Department of Veterans Affairs (VA) treatment record states that the Veteran was diagnosed with Type II diabetes mellitus. The VA physician clarified that “having gestational diabetes is a risk factor for later developing diabetes mellitus Type II.” The Veteran was diagnosed with gestational diabetes mellitus during active service. She was diagnosed with Type II diabetes mellitus following service separation. A VA physician has indicated that gestational diabetes mellitus is a risk factor for the development of Type II diabetes mellitus. Given such facts, the Board of Veterans’ Appeals (Board) concludes that the evidence is in at least equipoise as to whether the diagnosed Type II diabetes mellitus originated during active service. Resolving all reasonable doubt in the Veteran’s favor, the Board concludes that service connection for Type II diabetes mellitus is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for recurrent lumbar spine disability is remanded. The Veteran contends that service connection for a recurrent lumbar spine disability is warranted as the claimed disability was manifested during active service as the result of multiple in service falls. At the February 2020 Board hearing, the Veteran testified that she had injured her lumbar spine on several occasions during active service. She clarified that she had injured her lumbar spine when she “fell down the steps going down to lower base;” had reinjured her lumbar spine “bringing a five-gallon can of paint off the pier;” and again injured her lumbar spine when she fell down some stairs at the Portsmouth, Virginia, Naval Hospital. The service treatment records reflect that the Veteran was seen for lumbar spine complaints on several occasions. A February 1983 treatment record states that the Veteran complained of back pain between the shoulder blades and was diagnosed with low back muscle strain. A July 1983 treatment record conveys that the Veteran complained of mid back pain and was diagnosed with muscle spasms. A February 1984 treatment record notes that the Veteran complained of low back pain. A November 1984 treatment entry states that the Veteran was struck in the back with a mop handle. Treating medical personnel removed a splinter from the mid back area. A diagnosis of resolving foreign body excision was advanced. A March 1985 treatment record conveys that the Veteran complained of right upper back and subscapular pain. The Veteran was diagnosed with right posterior thoracic muscle strain. An August 1985 treatment entry states that the Veteran reported experiencing back pain after having fallen down some stairs. An October 1985 hospital admission record notes that the Veteran reported back aches after lifting five-gallon pain can in 1982. The report of a June 2015 VA spine examination states that the Veteran was diagnosed with lumbosacral degenerative disc disease and spondylosis; acute right posterior thoracic muscle strain; and low back muscle strain. The examiner concluded that “the condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event, or illness.” He commented that: “she had only acute self limited muscular pain in military;” “there is no finding of any skeletal or disc disease in military;” “there is no nexus connecting the muscular back pain with the current disc and facet joint related back pain;” and “she is at appropriate age for spondylosis.” The examiner did not discuss the relationship between the multiple documented in service traumas and the diagnosed lumbosacral spine disabilities. Given such deficiency, the Board finds that the examination report is of limited probative value. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). In light of the cited deficiency in the June 2015 examination report, the Board finds that further VA spine evaluation is needed. Clinical documentation dated after August 2020 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran’s claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). 2. Entitlement to service connection for a right shoulder disability is remanded. The Veteran asserts that service connection for a right shoulder disability is warranted as the disability was initially manifested as the result of an in service injury. The service treatment records indicate that the Veteran was seen for shoulder area pain. A February 1983 treatment record states that the Veteran complained of pain between the shoulder blades. An assessment of low back muscle strain was advanced. The report of a June 2015 VA shoulder examination states that the Veteran reported experiencing right shoulder problems since active service. Contemporaneous X ray studies of the right shoulder revealed “irregularity related to the lateral aspects of the bilateral acromions which suggest previous injuries.” The Veteran was diagnosed with right shoulder rotator cuff tendonitis and acromioclavicular joint osteoarthritis. The examiner concluded that “the condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in service injury, event, or illness.” He commented that: “currently, she has radiographic findings of right not left acromioclavicular osteoarthritis, and suggestion of right rotator cuff injury;” no right shoulder injury in the military injury;” and “no nexus connecting her supposed right shoulder injury.” The VA physician did not address the contemporaneous X ray findings consistent with right shoulder trauma and their relationship to the Veteran’s subjective history of in service right shoulder trauma. Given such an omission, the Board finds that the examination report is of essentially no probative value and further VA shoulder examination is necessary. 3. Entitlement to service connection for bilateral hearing loss is remanded. The Veteran asserts that service connection for bilateral hearing loss is warranted as the claimed disability was precipitated by her conceded in service noise exposure. The service treatment records do not refer to hearing loss disability. A January 1986 treatment record does state that the Veteran complained of difficulty hearing out of the right ear for the prior two days. The Veteran was diagnosed with acute right otitis media. At the February 2020 Board hearing, the Veteran testified that she experienced progressively worsening hearing loss for which she has been seen by doctors. Clinical documentation of the cited treatment is not of record. Given the Veteran’s competent testimony as to experiencing progressive hearing loss, the Board finds that further audiological evaluation is needed. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who treated her for any lumbosacral spine, right shoulder, and hearing loss disabilities. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Associate with the record any VA medical records for treatment provided since August 2020 not already of record. 3. Schedule the Veteran for a VA spine examination conducted by a medical doctor who has not previously examined her to assist in determining the etiology of any identified recurrent lumbar spine disability and its relationship, if any, to active service. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all recurrent lumbosacral spine disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified recurrent lumbosacral spine disability had its onset during active service or is related to any incident of service, including the Veteran’s documented in service lumbosacral spine trauma. 4. Schedule the Veteran for a VA shoulder examination conducted by a medical doctor who has not previously examined her to assist in determining the etiology of any identified recurrent right shoulder disability and its relationship, if any, to active service. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all recurrent right shoulder disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified recurrent right shoulder disability had its onset during active service or is related to any incident of service, including the Veteran’s documented in service shoulder area complaints. The examiner should specifically discuss the June 2015 VA X ray findings consistent with prior right shoulder trauma. 5. Schedule the Veteran for a VA audiological examination to assist in determining the etiology of any identified hearing loss disability and its relationship, if any, to active service. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (Continued on the next page)   (a) Diagnose all hearing loss disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified hearing loss disability had its onset during active service or is related to any incident of service, including the Veteran’s conceded in service noise exposure and documented right otitis media. J. T. HUTCHESON Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E.O., 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.