Citation Nr: 21009131 Decision Date: 02/19/21 Archive Date: 02/19/21 DOCKET NO. 15-40 166 DATE: February 19, 2021 REMANDED Entitlement to service connection for diabetes mellitus is remanded. Entitlement to service connection for a right leg disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from July 1982 to September 1986. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a June 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In December 2018, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is associated with the claims file. In December 2019, the Board last remanded these matters to the RO for further development. Although the Board sincerely regrets the additional delay, a remand is necessary to ensure that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. 1. Entitlement to service connection for diabetes mellitus Unfortunately, the Board finds that a remand is again warranted for further evidentiary development to ensure compliance with the prior Board remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In this regard, in the December 2019 Board remand, the Board instructed the VA examiner to address the Veteran’s contention that while his diabetes mellitus was not diagnosed until approximately five years after service, his onset could have occurred (untreated with symptoms) at an earlier date. Although the September 2020 VA examiner found that the Veteran’s diabetes mellitus, type 1, was not related to service because he was diagnosed with this condition five years after his discharge from service and noted that diabetes mellitus, type 1, is thought to be an autoimmune disorder that may have a genetic tendency, the VA examiner did not address the Veteran’s contention as instructed to do so in the December 2019 Board remand. Moreover, the Veteran’s August 1986 Report of Medical History reflects that the Veteran reported that he sometimes got headaches and felt dizzy and reported frequent or painful urination. Accordingly, the Board finds that a remand is warranted to obtain an addendum opinion to account for the portion of the September 2020 VA opinion that does not address the Veteran’s lay statements. Specifically, an adequate opinion and rationale must discuss the Veteran’s contention that while his diabetes mellitus was not diagnosed until five years after service, he could have experienced an earlier onset with untreated symptoms and should consider the Veteran’s reports of dizzy spells and frequent urination proximate to his discharge from service. 2. Entitlement to service connection for a right leg disability Unfortunately, the Board finds that a remand is also warranted for the Veteran’s service connection claim for a right leg disability as there has not been substantial compliance with the prior Board remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In this regard, in the December 2019 Board remand, the Board instructed the VA examiner to specifically consider the Veteran’s lay statements concerning problems with his right leg due to carrying heavy loads and repelling from helicopters in service. Although the October 2020 VA examiner found that the Veteran’s current diagnoses could be patellofemoral syndrome (PFS) or quadriceps/patellar tendinitis and that such were not related to service, the VA examiner failed to consider or address the Veteran’s above contentions as instructed to do so. Additionally, the VA examiner based his opinion, in part, on the finding that there was no evidence in the record of complaints and/or diagnoses of a right knee condition until 2014 and/or decades after the Veteran’s discharge from service. However, upon review of the medical evidence, private treatment records reflect reports of leg pain prior to 2014. Specifically, a September 1999 private treatment record reflects that the Veteran experienced occasional right leg pain early in the morning while a January 2000 private treatment record indicates the Veteran experienced low back pain, thigh, and occasional knee pain especially with walking distances. In October 1999, the Veteran also underwent knee x-rays due to his leg and knee pain. As such, the October 2020 VA negative nexus opinion is based on an inaccurate factual premise. Accordingly, a remand is warranted for an addendum VA opinion that addresses the Veteran’s lay statements and considers all the evidence of record. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA treatment records. The last VA treatment of record is dated August 2020. 2. Then, obtain an addendum VA opinion from an appropriate medical professional concerning the Veteran’s service connection claim for diabetes mellitus. The claims file, to include a copy of this Remand, must be made available to and be thoroughly reviewed by the VA examiner. The VA examiner is asked to respond to the following: Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s diagnosed diabetes mellitus had an onset in service or is otherwise related to the Veteran’s service? In providing the above opinion, the examiner MUST ADDRESS the Veteran’s contention that while his diabetes mellitus was not diagnosed until approximately five years after service, his onset could have occurred with untreated symptoms at an earlier date, and DISCUSS how this contention relates to the Veteran’s claim. The VA examiner should also consider and address as appropriate: (1) the August 2000 private treatment record reflecting that the Veteran was diagnosed with diabetes mellitus in June 1991 and was started on insulin immediately; and (2) the May 2018 medical opinion from the Veteran’s treating physician at the VA diabetes clinic noting that it is possible for the autoimmune process of type 1 diabetes to occur earlier, and this could have begun during the Veteran’s time in service, but that the Veteran’s service medical records were not available to the treating physician to review and he did not recognize anything in the current, available medical record that demonstrated an earlier intervention would have changed the course of the disease or the Veteran’s current clinical condition. A complete rationale must be provided for all opinions. A discussion of the relevant facts and medical principles involved would be of considerable assistance to the Board. 3. Obtain an addendum VA opinion from an appropriate medical professional concerning the Veteran’s service connection claim for a right leg disability. The need for an in-person examination is left to the discretion of the VA examiner. The claims file, to include a copy of this Remand, must be made available to and be thoroughly reviewed by the VA examiner. The VA examiner is asked to respond to the following: (a) Identify all diagnoses related to the Veteran’s service connection claim for a right leg disability throughout the appeal period and discuss any conflicting evidence as necessary. The examiner should consider (1) the October 2020 VA examiner’s finding that the Veteran does not have right knee degenerative joint disease but may have PFS or quadriceps tendon/patellar tendonitis; (2) the September 2019 VA examination reflecting a diagnosis of a right knee strain and right hip strain; (3) the March 2014 VA examination reflecting a diagnosis of osteoarthritis of the bilateral knees; (4) the June 2013 VA treatment record reflecting a knee strain diagnosis; and (4) the VA treatment and private records reflecting peripheral neuropathy (b) For each identified disability, other than the Veteran’s already service-connected right lower extremity radiculopathy of the sciatic and femoral nerves, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that such had an onset in service or is otherwise related to service? In providing the above opinion, the VA examiner MUST ADDRESS the Veteran’s lay statements regarding problems with his right leg due to carrying heavy loads and repelling from helicopters in service, including his statements of continuity of symptomatology since service. For example, during the March 2014 VA examination, he reported occasional flares of knee pain with overuse injuries and reported during the September 2019 VA examination that his knee and hip condition occurred gradually overtime with road marching in service. The examiner should also consider and address as appropriate: (1) the August 1986 Report of Medical History where the Veteran reported cramps in his legs; (2) the 1999 and 2000 private treatment records reflecting reports of leg and knee pain; (3) the December 2018 VA treatment record reflecting bilateral leg and arm cramping with a possible cause including diabetes mellitus; and (4) the February 2020 VA examiner’s finding that the Veteran’s right knee symptoms are likely due to deconditioning with diabetes mellitus, hypertension, and human immunodeficiency virus history. A complete rationale must be provided for all opinions. A discussion of the relevant facts and medical principles involved would be of considerable assistance to the Board. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Amanda Purcell, 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.