Citation Nr: 21022751 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 08-37 532 DATE: April 19, 2021 REMANDED Entitlement to service connection for diabetes mellitus, to include as secondary to service-connected disabilities, is remanded. Entitlement to service connection for left upper extremity diabetic neuropathy is remanded. Entitlement to service connection for right upper extremity diabetic neuropathy is remanded. Entitlement to service connection for left lower extremity diabetic neuropathy is remanded. Entitlement to service connection for right lower extremity diabetic neuropathy is remanded. REASONS FOR REMAND The Veteran had active service from June 1964 to December 1964 and from March 2005 to December 2005. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a June 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In a July 2019 decision, the Board, in pertinent part, denied service connection for diabetes mellitus and residuals, including diabetic neuropathy of the bilateral upper and lower extremities. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). In May 2020, the Court granted the parties’ Joint Motion for Remand (JMR), vacated the decision, and remanded the issue back to the Board for further adjudication in compliance with the Order. The Claims on Appeal are Remanded. Regarding the claim for diabetes mellitus, the Veteran contends that it was incurred in service. Alternatively, it is secondarily related to his service-connected disabilities, including medications taken for the service-connected posttraumatic stress disorder (PTSD). As addressed in the JMR, an adequate VA examination is needed to determine the etiology of thereof. The VA examinations to date have failed to address elevated in-service blood sugar reading, indications that the Veteran was placed on a restrictive diet while in service, and whether his service-connected disabilities caused and/or aggravated his diabetes mellitus. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Given these deficiencies in the record, a remand is necessary. The Veteran’s claims for entitlement to service connection for residuals, including diabetic neuropathy of the bilateral upper and lower extremities, are deemed inextricably intertwined with the issue of entitlement to service connection for diabetes mellitus, which is being remanded herein. Therefore, a final decision on the issues of service connection for the said residuals cannot be rendered at this time. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). The matters are REMANDED for the following action: 1. Associate all outstanding VA treatment records with the Veteran’s electronic claims file. 2. After completing the above-specified development, provide the Veteran’s claim file to a qualified clinician so that a supplemental opinion may be provided to determine the etiology of his diabetes mellitus. The entire claims file and a copy of this remand must be made available to the examiner for review. A physical examination of the Veteran or telehealth examination is only required if deemed necessary by the clinician. The examiner must take a detailed history from the Veteran. If there is any clinical or medical basis for corroborating or discounting the reliability of the history provided by the Veteran, the examiner must so state, with a complete explanation in support of such a finding. Although an independent review of the claims file is required, the Board calls the clinician’s attention to: a. The March 15, 2005 Radiology record indicating a blood sugar level of 178. b. The June 27, 2005, primary care note indicating that the Veteran was on a diabetes-specific diet. c. The Veteran’s April 6, 2011 statement of a secondary relationship between his diabetes and his service-connected disabilities, including his medication of Fluoxetine and Citalopram for his acquired psychiatric disability. d. Treatise evidence cited: i. B. Luna and M. Femglos, Drug-Induced Hyperglycemia 286 JAMA16 (2002), indicating that certain medications can cause hyperglycemia/excessive circulation of glucose in blood plasma. ii. Mayo Clinic Online Hyperglycemia in Diabetes article indicating that an infarction, for example, and physiological stress can cause hyperglycemia: http//www.mayochnic.com/health/hyperglycemia/DS01168/METHOD iii. Sarah E. Capes MD; Dereck Hunt, MD, MSc; Klas Malmberg, MD, PhD.; Parbeen Pathak BSc, MD; Hertzel C. Gerstein, MD, MSc.; Stress Hyperglycemia and Prognosis of Stroke in Nondiabetic and Diabetic Patients, 32 Stroke10 (2001)). The examiner must opine on the following: a. Is it at least as likely as not (50 percent probability or greater) that the current diabetes mellitus had onset in service or is etiologically directly related to active service. b. Is it at least as likely as not (50 percent probability or greater) that the current diabetes mellitus is caused by the Veteran’s service-connected disabilities, to include medications taken, including Fluoxetine and Citalopram, for the service-connected acquired psychiatric disorder. c. Is it at least as likely as not (50 percent probability or greater) that the current diabetes mellitus is aggravated (worsened in severity beyond the natural progression of the disease) by the Veteran’s service-connected disabilities, to include medications taken for the service-connected acquired psychiatric disorder. The examiner is reminded that for a secondary opinion to be adequate, he/she must provide separate rationales for both causation and aggravation. Atencio v. O’Rourke, 30 Vet. App. 74 (2018). The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above-requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such a conclusion. 3. Then, readjudicate the claims. If any decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. N. Stevens Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Teague, 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.