Citation Nr: 21010350 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 17-07 232 DATE: February 24, 2021 REMANDED Entitlement to a rating in excess of 20 percent for service-connected diabetes mellitus type II (hereinafter diabetes) is remanded. REASONS FOR REMAND The Veteran had honorable active service with the United States Army from March 1968 to January 1971. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an August 2015, and February 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). Although further delay is regrettable, a remand is necessary for a new VA examination and development. The Veteran contends that in November 2018 he had an episode of low blood sugar. He reported that he was hospitalized in a VA medical center hospital for three days. As a result, he now sees an endocrinologist at the VA. He also reported that he has continued to have episodes of low blood sugar and that he continues to require insulin medications. See Correspondence received September 2019. First, VA has a duty to assist Veteran’s in obtaining records. In particular, VA will make as many requests as are necessary to obtain relevant records from a Federal department or agency. See 38 C.F.R. § 3.159(c)(2). The VA also has the duty to notify the Veteran if they are reasonably certain that records do not exist or further attempts to find them would be futile. See 38 C.F.R. § 3.159(e)(1). The Veteran has reported that he has recent treatment from around 2018 to the present for diabetes. Including one visit to a VA medical center hospital for low blood sugar. The VA treatment records available in the claims file are only to June 2017. In light of the likely missing VA medical records, a remand is required to obtain any relevant treatment records. VA’s duty to assist also includes providing a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of a disability. See Peters v. Brown, 6 Vet. App. 540, 542 (1994). See also Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (determining that Board should have ordered contemporaneous examination of Veteran because a 23-month old exam was too remote in time to adequately support the decision in an appeal for an increased rating); and Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (holding that where the record does not adequately reveal the current state of that disability, the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination). The Veteran was last afforded a VA examination to assess the severity of his service-connected diabetes in December 2016. See C&P Exam dated December 2016. The Veteran reported that his diabetes has worsened since his last examination. See Correspondence received September 2019. Therefore, the Board remands the claim for a contemporaneous examination to determine the severity of the Veteran’s service-connected diabetes and to rate the Veteran’s condition accordingly. The matters are REMANDED for the following action: 1. Take all appropriate actions to attempt to obtain potentially missing VA treatment records, including VA hospital records described by the Veteran. See Correspondence received September 2019. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Afterwards, schedule the Veteran for an appropriate VA examination to determine the nature and current severity of the Veteran’s diabetes. The entire claims file and a copy of this remand should be made available to the examiner for review, and such review should be noted in the examination report. All necessary tests and studies should be conducted. The examiner’s attention is called to the contentions that the Veteran has periods of low blood sugar and reports using insulin. (Continued on the next page)   3. A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what additional evidence, if any, would allow for a more definitive opinion. 4. If any benefit sought on appeal is not granted, the Veteran and his representative should be provided a Supplemental Statement of the Case (SSOC) and afforded the requisite opportunity to respond before the case is returned to the Board. B. MULLINS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Associate Counsel, C. Parnell 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.