Citation Nr: 21015266 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 15-46 738 DATE: March 17, 2021 REMANDED Service connection for type II diabetes mellitus, to include exposure to environmental hazards during Gulf War service and as secondary to service-connected disability.   REASONS FOR REMAND The Veteran served on active duty in the United States Navy from December 1985 to April 1995. The case is on appeal from a December 2013 rating decision. In August 2018, the Board remanded the appeal for additional development. Service connection for type II diabetes mellitus, to include exposure to environmental hazards during Gulf War service and as secondary to service-connected disability. Pursuant to the Board’s August 2018 remand, a VA opinion was obtained in July 2019. The opinion states that it is less than likely that the Veteran’s diabetes is related to service, noting normal glucose levels at separation and the diagnosis of diabetes in December 2011. In view of the Veteran’s assertion with respect to weight gain/obesity in January 2021 and the July 2019 letter from his doctor noting a dramatic increase in body weight since taking prescribed medications for service-connected migraines, and that use of migraine treatment medication is a serious contributor and a very possible cause of his development of insulin resistance, together with the recent case of Walsh v. Wilkie, 32 Vet. App. 300, 305-07 (2020) (holding that obesity as an “intermediate step” in a causal chain for service connection can be established on either a causal or aggravation basis), the July 2019 VA opinion is not entirely sufficient. Thus, the Board finds that remand is warranted for a new etiology opinion, to include addressing obesity. The matter is REMANDED for the following action: Schedule the Veteran for an examination (or telehealth interview, records review, etc. if an in-person examination is not feasible) to determine the nature and etiology of diabetes. The entire claims file must be reviewed by the examiner. The examiner is to conduct all indicated tests. The examiner is asked to address each of the following: (a.) Whether diabetes is at least as likely as not (a 50 percent or greater probability) related to an in-service injury, event, or disease. (b.) Whether diabetes is at least as likely as not (a 50 percent or greater probability) caused by or aggravated by service-connected migraine headaches. The examiner should consider the effects of any medication the Veteran takes to treat migraines. (c.) Whether it is at least as likely as not (a 50 percent or greater probability) that migraine headaches, either alone or in combination with service-connected recurrent microhematuria with a simple renal cyst, caused or aggravated the Veteran’s weight gain or obesity, and if so, whether it is at least as likely as not (50 percent or greater probability) that the weight gain or obesity resulting from the service-connected disability or disabilities was a substantial factor in causing or aggravating his diabetes; and, if so, whether it is at least as likely as not (50 percent or greater probability) that diabetes would have occurred but for weight gain/obesity caused or aggravated by the service-connected disability or disabilities. Aggravation is an increase in severity beyond the natural progress of the disease or temporary flare-up. If aggravation is found, the examiner should identify a baseline level of severity of the Veteran’s diabetes by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the Veteran’s diabetes. Rationale for all opinions expressed should be provided. If the reviewing clinician is unable to provide the requested opinions without resort to speculation, it must be so stated, and he or she must provide the reasons why an opinion would require speculation. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Taylor 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.