Citation Nr: 21026293 Decision Date: 04/30/21 Archive Date: 04/30/21 DOCKET NO. 16-35 562A DATE: April 30, 2021 REMANDED Entitlement to service connection for diabetes mellitus, type 2 is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for left foot peripheral neuropathy is remanded. Entitlement to service connection for right foot peripheral neuropathy is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1980 to August 2000. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). In March 2019, the Board reopened the Veteran’s claim for service connection for diabetes mellitus. At such time, the Board also remanded each of the claims listed above for further development. 1. Entitlement to service connection for diabetes mellitus is remanded. The Veteran contends that service connection is warranted for diabetes mellitus, Type 2. The Veteran is currently service connected for hypertension, and he submitted an article indicating that high blood pressure was a risk factor for diabetes. See February and May 2018 Correspondence. The Veteran also claimed that he had elevated blood sugar readings and obesity in service and believes that these factors caused his diabetes mellitus. See September 2020 Correspondence. The Veteran was afforded a VA examination in April 2018, at which time the examiner noted a diagnosis of diabetes mellitus, type 2. The examiner noted that the Veteran’s medication/insulin did not help his condition and that the Veteran was unable to exercise. The examiner opined that it was less likely than not that the Veteran’s diabetes mellitus was incurred in or caused by the claimed in-service injury, event, or illness. The examiner rationed that the Veteran developed hyperglycemia five to seven years following discharge. The examiner also noted that the Veteran underwent glucose testing in 2007 at which time his A1c was normal. The examiner further reported that it was not until 2009 when the Veteran required medication. The Veteran was also afforded a VA examination in September 2019, at which time an examiner similarly noted that the Veteran had a diagnosis of diabetes mellitus, type 2. The examiner opined that it was less likely than not that the Veteran’s diabetes mellitus was due to his service-connected hypertension. The examiner rationed that diabetes mellitus is a separate entity from his service-connected hypertension and unrelated to it. The examiner also reported that medical literature does not support a medical relationship between diabetes mellitus and hypertension. The Board finds that the rationale supporting the May 2018 and September 2019 VA examinations is inadequate. Specifically, the May 2018 examiner did not provide an opinion with adequate rationale concerning whether the condition was related to service on a direct basis, regardless of its post-service onset. Further, the September 2019 examiner did not seem to consider the article submitted by the Veteran, which indicated that hypertension (for which he is service connected) is a risk factor for diabetes complications. Additionally, there is evidence of record which supports that a service-connected disability, to specifically include depression, a back disability, and/or bilateral lower extremity radiculopathy, caused the Veteran to be inactive and resultantly, he became obese which in turn may have caused or aggravated his diabetes mellitus. The Board recognizes that obesity may serve as an “intermediate step” between a service-connected disability and a current disability that may be service connected on a secondary basis under 38 C.F.R. § 3.310(a). See Walsh v. Wilkie, 30 Vet. App. 300 (2020); Garner v. Tran, No. 18-5865, 2021 U.S. App. Vet. Claims LEXIS 81, at 15 (Vet. App. Jan. 26, 2021); VAOGCPREC 1-2017. In such a case, the evidence would need to reflect that (1) a service-connected disability or disabilities caused the Veteran to become obese or aggravated the Veteran’s obesity, (2) the obesity or aggravation of obesity resulting from service-connected disability or disabilities was a substantial factor in causing another disability, and (3) the disability would not have occurred but for the obesity caused by the Veteran’s service-connected disability or disabilities or the obesity aggravated by the service-connected disability or disabilities. Walsh, 30 Vet. App. at 306-7. An addendum opinion should be obtained on remand. 2. Entitlement to service connection for sleep apnea is remanded. The Veteran contends that service connection is warranted for sleep apnea. The Veteran is currently service connected for hypertension, and he submitted articles indicating that high blood pressure can cause sleep apnea or worsen breathing in patients already affected by sleep apnea and that the most common cause of sleep apnea is obesity and excess weight. See February 2018 Correspondence and September 2020 Correspondence. In the September 2020 Correspondence, the Veteran also included handwritten notations that he snored, had shortness of breath, excess weight, and a thick neck in service. Additionally, the Veteran identified that he had hay fever and sinus problems in service, and that he believed that was the cause of his sleep apnea. The Veteran was afforded a VA examination in September 2019, at which time the examiner noted that the Veteran had a diagnosis of obstructive sleep apnea. The examiner noted that the condition onset in 2017 and that the Veteran experienced snoring and daytime somnolence. The examiner opined that it was less likely than not that the Veteran’s sleep apnea was incurred in or caused by an in-service injury, event, or illness. The examiner rationed that sleep apnea risk factors included advancing age, male gender, obesity, craniofacial morphology or upper airway soft tissue abnormalities, smoking, nasal congestion, and family history. The examiner also reported that a nexus was not established as the Veteran’s sleep apnea was not diagnosed until 16 years after separation. The examiner also opined that it was less likely than not that the Veteran’s sleep apnea was related to his service-connected hypertension. In support of the opinion, the examiner cited to the risk factors listed above, to specifically include obesity and neck circumference as the more likely etiologies. The Board finds that the September 2019 VA opinion is inadequate. In this regard, while the September 2019 examiner identified various risk factors for sleep apnea, the examiner failed to provide a reasoned medical explanation for concluding that the Veteran’s sleep apnea was less likely than note related to service and also did not identify which risk factors were applicable and significant to the Veteran. Additionally, the examiner did not seem to consider the article submitted by the Veteran, which indicated that hypertension (for which he is service connected) is a risk factor for the development of sleep apnea. Further, the examiner did not consider and identify the Veteran’s lay statements regarding onset and continuity of his symptoms. Additionally, there is evidence of record which supports that a service-connected disability, to specifically include depression, a back disability, and bilateral lower extremity radiculopathy, caused the Veteran to be inactive and resultantly, he became obese which in turn may have caused or aggravated his sleep apnea. An addendum opinion should be obtained on remand. 3. Entitlement to service connection for left foot peripheral neuropathy, to include as secondary to diabetes mellitus is remanded. 4. Entitlement to service connection for right foot peripheral neuropathy, to include as secondary to diabetes mellitus is remanded. The Veteran contends that service connection is warranted for left and right foot peripheral neuropathy, to include as secondary to diabetes mellitus. A September 2019 VA examination confirmed a diagnosis of bilateral lower extremity peripheral neuropathy. Also, in a separate September 2019 VA examination, an examiner noted that the Veteran had diabetes mellitus, Type 2 with complications of diabetic peripheral neuropathy Because a decision on the remanded issue of entitlement to service connection for diabetes mellitus could significantly impact a decision on the issues of entitlement to service connection for left foot peripheral neuropathy and right foot peripheral neuropathy, the issues are inextricably intertwined. Therefore, adjudication must be deferred at this time. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (the prohibition against the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). The matters are REMANDED for the following action: 1. DIABETES MELLITUS, TYPE 2: Obtain an addendum opinion by an appropriate clinician to determine the nature and etiology of the Veteran’s diabetes mellitus. Then, provide the following opinions: (i) Is it at least as likely as not (50 percent or greater probability), that the Veteran’s diabetes mellitus had its onset in, or is otherwise related to his active duty service? In offering this opinion, the examiner must consider the full record, to include the Veteran’s lay statements that he had a high blood sugar reading in service and was prediabetic at such time. A clearly-stated rationale for any opinion offered should be provided and must not be based solely on the lack of any documented problems in the Veteran’s service treatment records. In doing so, the examiner must consider the Veteran’s March 1990 in-service glucose reading of 124 and albumin reading of 4.4 and determine the interplay of such glucose/albumin readings with the articles (regarding prediabetes) that the Veteran submitted. (ii) Is it at least as likely as not (50 percent or greater probability) that diabetes mellitus was caused or aggravated (worsened) by a service-connected disability/disabilities? In doing so, the examiner should also specifically consider whether the Veteran’s diabetes mellitus was caused or aggravated by his service-connected hypertension, to include consideration of the submitted CDC article entitled “One-Third of Adults with Diabetes Still Don’t Know They Have It” and the WebMD article entitled “Early Symptoms of Diabetes.” (iii) Is it at least as likely as not that obesity served as an “intermediate step” between the Veteran’s service-connected disability/disabilities and diabetes mellitus? Please answer each of the following questions: a. Is it at least as likely as not that the Veteran’s service-connected disability/disabilities, to specifically include his service-connected major depressive disorder, lumbar spine degenerative arthritis, and bilateral lower extremity radiculopathy, caused the Veteran to become obese or aggravated the Veteran’s obesity? b. If so, was the obesity that resulted from or was aggravated by the service-connected disability/disabilities a substantial factor in causing diabetes mellitus? c. Would diabetes mellitus not have occurred, but for the obesity caused by or aggravated by the service-connected disability/disabilities? 2. SLEEP APNEA: Obtain an addendum opinion by an appropriate clinician to determine the nature and etiology of the Veteran’s sleep apnea. Then, provide the following opinions: (i) Is it at least as likely as not (50 percent or greater probability), that the Veteran’s sleep apnea had its onset in, or is otherwise related to his active duty service? In offering this opinion, the examiner must consider the full record, to include the Veteran’s lay statements that he snored, had shortness of breath, excess weight, and a thick neck in service. The examiner should also consider the September 1998 in-service notations of sinus pressure and possible hay fever and determine the interplay between such conditions and sleep apnea. A clearly-stated rationale for any opinion offered should be provided and must not be based solely on the lack of any documented problems in the Veteran’s service treatment records. (ii) Is it at least as likely as not (50 percent or greater probability) that sleep apnea was caused or aggravated by a service-connected disability/disabilities? In doing so, the examiner should specifically consider whether the Veteran’s sleep apnea was caused or aggravated by his service-connected hypertension, to include consideration of the submitted Cardiosmart article entitled “Sleep Apnea and High Blood Pressure: A Dangerous Pair.” (iii) Is it at least as likely as not that obesity served as an “intermediate step” between the Veteran’s service-connected disability/disabilities and sleep apnea? Please answer each of the following questions: a. Is it at least as likely as not that the Veteran’s service-connected disability/disabilities, to specifically include his service-connected major depressive disorder, lumbar spine degenerative arthritis, and bilateral lower extremity radiculopathy, caused the Veteran to become obese or aggravated the Veteran’s obesity? b. If so, was the obesity that resulted from or was aggravated by the service-connected disability/disabilities a substantial factor in causing sleep apnea? c. Would sleep apnea not have occurred, but for the obesity caused by or aggravated by the service-connected disability/disabilities? 3. Upon completion of the requested development and any additional development deemed appropriate, adjudicate the claims on appeal. If the determination remains unfavorable to the Veteran and his representative should be furnished a supplemental statement of the case which addresses all relevant evidence. The Veteran and his representative should be afforded the applicable time period in which to respond. Then, return the case to the Board. MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Hanson, Tiffany 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.