Citation Nr: 21015107 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 14-20 971 DATE: March 16, 2021 REMANDED Entitlement to service connection for diabetes, to include as secondary to and/or aggravated by a service-connected disability and/or exposure to petroleum smoke in service is remanded. Entitlement to service connection for hypertension, to include as secondary to diabetes and/or exposure to petroleum smoke in service is remanded. Entitlement to service connection for a liver condition, to include hemochromatosis and fatty liver disease, to include as secondary to and/or aggravated by diabetes and/or exposure to petroleum smoke in service is remanded. Entitlement to service connection for a heart condition, to include as secondary to diabetes and/or exposure to petroleum smoke in service is remanded. REASONS FOR REMAND The Veteran had active service from February 1982 to February 1992. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2012 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this matter in November 2018 and again in October 2020. 1. Entitlement to service connection for diabetes, to include as secondary to and/or aggravated by a service-connected disability and/or exposure to petroleum smoke in service is remanded. The Veteran has been afforded VA examinations and opinions regarding his claimed diabetes in 2018 and 2020. Unfortunately, neither opinion has adequately addressed whether his claimed diabetes was aggravated by his service-connected disabilities, to include the service-connected gastrointestinal disability. While the February 2020 VA examiner reported that there are no service connected conditions at this time that would as likely as not aggravate the Veteran’s diabetes, no rationale was provided as to why the service-connected disabilities do not cause or aggravate the Veteran’s claimed disability. Regarding the service-connected gastrointestinal disability the examiner provided a rationale was to why it would not cause the Veteran’s diabetes but not why his diabetes is not aggravated by the service-connected gastrointestinal disability. As such, the opinions are inadequate and a new opinion is necessary. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 2. Entitlement to service connection for hypertension, to include as secondary to diabetes and/or exposure to petroleum smoke in service is remanded. Regarding the Veteran’s claim for hypertension, he underwent relevant VA examinations in February 2020 and December 2020 wherein the Veteran was noted to have a diagnosis of hypertension, and the VA examiners offered unfavorable etiological opinions. However, the Board finds that the February 2020 opinion is based on an inaccurate factual premise. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). While the examiner noted that the Veteran’s service treatment records do not show a diagnosis of hypertension nor a chronicity of elevated blood pressures, blood pressure taken in service include readings of 132/100, 126/90 and 120/94. See service treatment records dated in March 1983, April 1986, and February 1992. In addition, the Veteran contends that his blood pressure is sometimes elevated secondary to his pain. See October 2018 VA treatment record. However, similar to the February 2020 opinion regarding diabetes, the February 2020 VA examiner opined that there are no service connected conditions at this time that would as likely as not cause or aggravate the Veteran’s hypertension without any rationale. Thus, remand is necessary in order to obtain an addendum opinion addressing the foregoing matters. See Nieves-Rodriguez, 22 Vet. App. 295; Barr, 21 Vet. App. 303, 312. 3. Entitlement to service connection for a liver condition, to include hemochromatosis and fatty liver disease, to include as secondary to and/or aggravated by diabetes and/or exposure to petroleum smoke in service is remanded. The Veteran’s claim for service connection for a liver disability was also previously remanded by the Board for a VA examination to clarify the nature and etiology of the diagnosed hemochromatosis. According to the March 2018 and February 2020 VA examination reports, he has hereditary hemochromatosis which causes excess iron to be stored in the liver and can affect the pancreas and lead to diabetes. While the private examiner reported the Veteran’s condition began in the 1990’s the VA examiners reported that the condition began in 2011. However, private treatment records reflect that the Veteran’s hereditary chromatosis began in 2010 and that he had longstanding poorly controlled iron levels. In any event, the diagnosis raises the question of whether the Veteran’s hemochromatosis is a developmental or congenital disease or defect. A developmental or congenital disease, even if hereditary, can be found to be service connected if it first manifests during active service. See VAOPGCPREC 67-90. On the other hand, a developmental or congenital defect cannot be service-connected, but if there is a superimposed injury or disease, service connection can be warranted for the additional disability. See VAOPGCPREC 82-90 (July 18, 1990); 38 C.F.R. §§ 3.303(c), 4.9, 4.127. The March 2018 and February 2020 VA examiners did not use the correct legal standard in the supporting rationales to the negative nexus opinions. Additionally, the February 2020 VA opinion regarding secondary service connection did not include any rationale for the negative opinions regarding hemochromatosis or fatty liver. See Nieves-Rodriguez, 22 Vet. App. 295; Barr, 21 Vet. App. 303, 312. Thus, an addendum opinion is warranted. 4. Entitlement to service connection for a heart condition, to include as secondary to diabetes and/or exposure to petroleum smoke in service is remanded. As previously noted, private treatment records and opinions from the Veteran’s treating physicians indicate that the claimed disorders including the claimed heart disorder, diagnosed as coronary artery disease and mild aortic sclerosis, may be secondary to and/or aggravated by the Veteran’s diabetes. Therefore, the Board is unable to adjudicate the claim until the above development is completed. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). The matters are REMANDED for the following actions: 1. Return the record, to include a copy of this Remand, to the VA examiner who conducted the February 2020 examinations pertaining to the Veteran’s liver disability. If the February 2020 VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinions. Following a review of the record, to include the diagnoses of hereditary hemochromatosis and fatty liver, the examiner should address the following inquiries: (a) Is the Veteran’s liver disability a congenital defect or a congenital disease? The term ‘defect’ is broadly defined as a structural or inherent abnormality or condition that is more or less stationary in nature. The term ‘disease’ is broadly defined as any deviation from or interruption of the normal structure or function of any part, organ, or system of the body that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown. (b) If it is determined this condition is a congenital defect, the examiner should opine as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran has an additional disability due to an in-service disease or injury superimposed upon such defect. In answering this question, the examiner should address the Veteran’s complaints of joint pain in service. (c) If instead it is determined that this condition is a congenital disease, does the evidence of record clearly and unmistakably show (i.e., it is undebatable) that the Veteran’s hereditary hemochromatosis existed prior to his entry onto active duty? (d) If the answer to (c) is yes, does the evidence of record clearly and unmistakably show that the preexisting disease was not aggravated by service or that any increase in disability was due to the natural progression of the disease? Please identify any such evidence with specificity. (e) If the answer to either (c) or (d) is no, is it at least as likely as not that the Veteran’s condition had its onset in service? (f) If the Veteran’s currently diagnosed hereditary hemochromatosis is neither a congenital defect nor congenital disease, the examiner should opine as to whether it at least as likely as not (a 50 percent probability or greater) that the condition is etiologically related to service or is either caused or aggravated (permanently worsened beyond the natural progress of the disorder) by a service-connected disability, to include the service-connected gastrointestinal disability. In offering such opinions, the examiner is asked to consider the Veteran’s service treatment records noting joint pain and private treatment records dated in July 2010 noting the diagnosis of hereditary hemochromatosis and notation of joint pains being related to longstanding poorly controlled iron levels. The examiner is also reminded that the absence of documented treatment in service or thereafter is not fatal to a service connection claim, and the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Thus, the examiner is to consider the totality of the record, and not just the absence of clinical treatment, in weighing the Veteran’s statements asserting symptomatology. A complete rationale should accompany each opinion provided and should be based on examination findings, historical records, and medical principles. 2. Return the record, to include a copy of this Remand, to the VA examiner who conducted the February 2020 examinations pertaining to the Veteran’s diabetes and heart disability. If the February 2020 VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinions. Following a review of the record the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s diabetes and/or heart disability, diagnosed as coronary artery disease and mild aortic sclerosis, are etiologically related to the Veteran’s period of service or are either caused or aggravated (permanently worsened beyond the natural progress of the disorder) by a service-connected disability. In offering such opinions, the VA examiner must consider the medical literature submitted by the Veteran which indicates a potential relationship between his service-connected gastrointestinal disorder and diabetes. The examiner is also reminded that the absence of documented treatment in service or thereafter is not fatal to a service connection claim, and the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. See Ledford, 3 Vet. App. at 89. Thus, the examiner is to consider the totality of the record, and not just the absence of clinical treatment, in weighing the Veteran’s statements asserting symptomatology. A complete rationale should accompany each opinion provided and should be based on examination findings, historical records, and medical principles. 3. Return the record, to include a copy of this Remand, to the VA examiner who conducted the February 2020 examination pertaining to the Veteran’s hypertension. If the February 2020 VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinions. Following a review of the record, the examiner should address the following inquiries: (a) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s hypertension had its onset in, or is otherwise related to, his military service, to include his in-service elevated blood pressure readings? (b) Did the Veteran’s hypertension manifest within one year of his separation from service? (c) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s hypertension is caused or aggravated by any service connected disability? In offering such opinions, the VA examiner must consider service treatment record blood pressure reading of 132/100, 126/90 and 120/94 dated in March 1983, April 1986, and February 1992, respectively, and the July 2018 VA treatment records wherein the Veteran reported that his pain increased his blood pressure. The examiner is also reminded that the absence of documented treatment in service or thereafter is not fatal to a service connection claim, and the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. See Ledford, 3 Vet. App. at 89. Thus, the examiner is to consider the totality of the record, and not just the absence of clinical treatment, in weighing the Veteran’s statements asserting symptomatology. A complete rationale should accompany each opinion provided and should be based on examination findings, historical records, and medical principles. 4. After the requested development has been completed, the AOJ should review any report or opinion to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the AOJ must implement corrective procedures. Cynthia M. Bruce Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Williams, 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.