Citation Nr: 21026726 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 10-37 039 DATE: May 3, 2021 ISSUES 1. Entitlement to service connection for residuals of a left shoulder injury. 2. Entitlement to service connection for a cervical spine disability, characterized as ruptured C4 of the neck. 3. Entitlement to service connection for a heart disability, to include as secondary to diabetes mellitus, type II. 4. Entitlement to service connection for diabetes mellitus, type II. REMANDED Entitlement to service connection for residuals of a left shoulder injury is remanded. Entitlement to service connection for a cervical spine disability, characterized as ruptured C4 of the neck is remanded. Entitlement to service connection for a heart disability, to include as secondary to diabetes mellitus, type II is remanded. Entitlement to service connection for diabetes mellitus, type II is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1982 to April 1982, and from July 1983 to January of 1986. The Service Personnel Records (SPRs) reflect additional brief periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA), including ongoing sets of days from January 9, 1991 to January 8, 1992, and from January 9, 1995 to January 8, 1996. See March 12, 2021 Appellate Brief, Attachments 1 and 5. In relevant part, this includes ACDUTRA from July 19, 1991 to July 3, 1991 for annual training. The Veteran also had a period of INACDUTRA from April 1, 1995 to April 2, 1995. Lastly, a NGB Form 22 reading National Guard Bureau Report of Separation and Record of Service received on July 14, 2020 establishes additional reserve service in the Air Force - Air National Guard of the United States (ANGUS) from February 2001 to January 1992. This matter is before the Board of Veterans Appeals (Board) on appeal from a November 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The Veteran testified before the undersigned Veterans Law Judge (VLJ) in May 2018. A copy of the hearing transcript has been associated with the claims file. At the hearing, the Veteran referenced experiencing migraine headaches associated with his claimed neck disability. The Veteran was advised at the time that he may file a separate claim for migraine headaches as secondary to the neck disability after the hearing. To date, no claim has been filed. Next, in June 2018, the Veteran submitted additional medical evidence. He waived RO review. Later, in August 2018, the Board remanded the issues currently on appeal for additional development. Next, in November 2019, a series of VA examinations with medical opinions were obtained in compliance with the Board Remand directives. Later, in June 2020, the Board remanded the issues for additional development. As a threshold issue, the VA DPRIS Response received on October 29, 2019 includes a clutch of Service Personnel Records (SPRs). There are additional records of "TD 7" service classified only as "paid inactive duty." This is consistent with the attachments later submitted by the Veteran, including in June 2020. The DPRIS records show several ongoing periods of paid inactive duty during the identified dates. A cache of service and medical documentation received in March 2021 contains both Service Personnel Records (SPRs) and Service Treatment Records (STRs) with clear scans so they are legibile. First are SPRs on pages 1 of 29 and clarified on page 5 of 29 showing paid inactive duty throughout 1991. The Board now is in possession of a clear, scanned copies. On page 1 the form shows credits for periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) from January 9, 1991 to January 8, 1992. Second, page 5 similarly shows periods of ACDUTRA and INACDUTRA from January 9, 1995 to January 8, 1996. The specific dates are listed below within these timeframes, each for only a matter of days. Incorporated in this file are Service Treatment Records (STRs) that corroborate these periods of service. The Veteran has referenced various injuries taking place over his long career. Of critical importance before weighing lay and medical evidence is whether the dates of various claimed injuries were during periods of active service. There are no additional DD-214s conclusively establishing that the Veteran had active service later in his career. However, in light of the Service Personnel Records (SPRs) with corroborating service medical documentation and lay evidence, the Board has verified additional relevant periods of service reflected on the title page. We will proceed. The Board generally observes that ACDUTRA in the Armed Forces is performed by Reserves for training purposes or by members of the National Guard of any state. 38 U.S.C. § 101 (22); 38 C.F.R. § 3.6 (c)(1). INACDUTRA, on the other hand, is the part-time duty in the Armed Forces performed by Reserves for training purposes or by members of the National Guard of any state. 38 U.S.C. § 101 (22); 38 C.F.R. § 3.6 (c)(1). Active military service includes any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty, or any period of INACDUTRA which the individual concerned was disabled or died from an injury (but not disease) incurred in or aggravated in line of duty. 38 U.S.C. § 101 (21) and (24)(2012); 38 C.F.R. § 3.6 (a) and (d) (2018). When a claim for service connection is based only on a period of ACDUTRA or INACDUTRA, there must be evidence that the appellant became disabled as a result of a disease or injury incurred or aggravated in the line of duty during that period of ACDUTRA or INACDUTRA for service connection to be granted. 38 U.S.C. §§ 101 (2), (22), (24); 38 C.F.R. § 3.6 (a); Donnellan v. Shinseki, 24 Vet. App. 167, 172 (2010); Acciola v. Peake, 22 Vet. App. 320, 324 (2008). In the absence of such evidence, the period of ACDUTRA or INACDUTRA would not qualify as "active military, naval, or air service," and the appellant would not qualify as a "veteran" for that period of ACDUTRA or INACDUTRA service alone. 38 U.S.C. § 101 (2), (24); Acciola, 22Vet. App. at 324. Generally, no presumptions (including the presumptions aggravation or for presumptive diseases) apply to periods of ACDUTRA and INACDUTRA unless "veteran" status is attained during those periods. Paulson v. Brown, 7 Vet. App. 466, 470 (1995). In this case, Veteran has now submitted documents that establish additional status based on INACDUTRA and ACDUTRA for periods of a matters of days throughout 1991 and 1995. See Appeals March 12, 2021 Appellate Brief (VSO IHP; Post remand Brief; Attorney Brief). For example, in Attachment 1 of the March 2021 Brief, the June 19, 1991 to July 13, 1991 period is classified as "annual tour" with duty code 4. It shows 15 points. This corresponds to the total of 15 (days) of active duty for training displayed in the summary above. See March 12, 2021 Appellate Brief, p.1 Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2018). Although the Board regrets any possible delay, a remand is necessary to ensure that the Veteran is afforded due process, and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. By way of background, a May 2020 Supplemental Statement of the Case (SSOC) was issued. In response, in the June 2020 Informal Hearing Presentation (IHP), the Veteran through his representative writes in part: The Veteran is essentially challenging the reasons and bases for the unfavorable decision. The Veteran remains in disagreement with the previous RO decisions and believes the evidence of record supports his claim. The Veteran contends he is entitled to service connection for diabetes mellitus type II, and a left shoulder, cervical spine, and cardiac conditions. The Veteran requests the Board grant his issues on appeal. We thank the Board for their time and consideration in this appeal. Days later, in June 2020, VA received a series of additional documents via Direct Upload, including some of those requested in the August 2018 Board Remand. The attached documents are labeled as exhibits. They include private treatment records showing various diagnoses. However, some of these records appeared blurry. This includes a Radiology Report from Berger Health System that shows the words MRI Impression and some text involving C6-C7, indicating the cervical spine. On remand, these private treatment records requested as part of the August 2018 Remand were to be resubmitted by the Veteran or the care provider in a legible format. Other documents including one labeled "Attachment 14" are also so blurry that they are illegible, though the original copies were type-written. The Veteran later submitted new copies of these labeled attachments. Importantly, the Veteran also submitted a June 12, 2020 Brief. In it, the Veteran outlines the various exhibits and contains lay evidence regarding injuries in service. The Board previously observed that this was obtained after the most recent VA examinations and SSOC. At that time, for example, there was still not evidence establishing that the Veteran was on active duty on June 30, 1991 when he reportedly fell on his left side, injuring his left shoulder. Indeed, as to any duty to provide an examination and/or seek a medical opinion, the Board highlighted in the June 2020 Remand that in the case of a claim for disability compensation, the assistance provided to the claimant shall include providing a medical examination or obtaining a medical opinion when such examination or opinion is necessary to make a decision on the claim. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Once VA undertakes the effort to provide an examination, it must obtain a fully adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Later, in Miller v. Wilkie, __ Vet. App. __, No. 18-2796, 2020 U.S. App. Vet. Claims LEXIS 64 at *19 (Jan. 16, 2020), the United States Court of Appeals for Veterans Claims (Court) held that when a VA examiner fails to address relevant lay evidence, and the Board fails to find the veteran not credible or not competent to offer that lay evidence, the proper remedy is for VA to obtain a new examination. The claims were subsequently remanded for supplemental VA examinations to consider the private treatment records and detailed lay evidence. 1. Entitlement to service connection for residuals of a left shoulder injury is remanded. The Board incorporates its discussion from the sections above by reference. By way of background, in a memorandum dated October 2008, VA determined that service treatment records (STRs) were unavailable for review. However, the Veteran later supplied copies. VA also made subsequent attempts to obtain copies of the Veteran's STRs. A VA Memorandum dated October 23, 2017, for example, shows that multiple searches did not uncover any service treatment records (STRs). At the May 2018 hearing, the Veteran testified regarding an in service injury to the left shoulder: Again, on active duty, a UTA day for the Air Guard. We were going through another exercise. I was also team leader of a decon unit for mobile decon of personnel troops and equipment. A portable cart with hoses, you know, strung out, spraying water, doing decontamination. And, while we're moving around, personnel guys moving hoses, grabbed me by my foot. I sort of tripped over the foot and, when I went down, I landed on my left shoulder with my arm in and, since that day, I mean, the only thing they could determine was the x-ray, broken ribs, that type of stuff is noted here, but my left shoulder range of motion, I cannot lift my left arm above my head very long at all. And, I think that that fall, free fall with no supporting or no way to catch myself onto the asphalt, I think that contributed to this injury as well. The Veteran reported that the injury occurred on June 30, 1991. The Veteran highlighted that although treatment providers documented a ribs injury, the related report specifies that the Veteran landed on his left shoulder. At the May 2018 hearing, the Veteran identified potentially relevant outstanding private treatment records. Next, in August 2018, the Board remanded the issues to allow VA to obtain authorization and request these records. In November 2019, the Veteran was afforded a VA shoulder examination. The VA examiner identified acromioclavicular joint osteoarthritis. The Veteran stated that around 2001 he injured his left shoulder after falling onto his shoulder. He was engaged in decontamination of equipment. Imaging revealed mild degenerative changes of the AC joint. Next, the VA examine rendered a negative nexus opinion for the left shoulder. The VA examiner reasoned: The veteran states that around 2001 while engaging in decontamination exercise during training he fell on his left shoulder, resulting in injury. He had no x-rays at that time and had not had any until those accompanying the current examination dated 11/18/2019 which show degenerative joint disease of the AC joint. However, I was unable to locate any entries in the STRs documenting an injury to the left shoulder. Should such entries be located, I will reassess my current opinion, but until that time, there is no evidence that his current DJD of the AC joint had its genesis during military service. Since then, in June 2020, the Veteran submitted additional lay and medical evidence. In the June 2020 Brief, he highlighted in part that the VA examiner told him that he had DJD of the AC joint, and that he would "correct his opinion and service connect the left shoulder if I could find the report that showed I had an injury during military service." Unfortunately, the private treatment provider, Dr. F. D., Chiropractor, only keeps records for ten years. Nevertheless, the Veteran provided probative new lay statements regarding an injury. Following the June 2020 Board Remand, the Veteran submitted legibile medical evidence and was afforded a November 2020 battery of VA examinations with medical opinions. As part of the November 2020 VA examinations is a VA shoulder examination with medical opinion offered by H. P. H. P. rendered a negative nexus opinion, with detailed rationale: The Veteran reports that he injured his left shoulder in 1991 when he had a fall onto his left shoulder. There is evidence in the treatment record of a fall that occurred in July 1991, at which time the Veteran landed on his left side. There is no evidence or report of a left shoulder injury at the time of the fall. The Veteran has current evidence of mild left AC joint osteoarthritis. There is no evidence of continuity of care of a left shoulder condition that began in 1991, nor evidence of a left shoulder injury during active duty service prior to 1991. The Veteran does report that he had treatment but records cannot be obtained. He does not endorse any left shoulder injury or symptoms prior to the fall in 1991. There is no evidence of a line of duty determination regarding the injury in 1991. Veteran's only verified periods of active duty service are from 01/13/1982 to 04/07/1982 and 07/11/1983 to 01/07/1986. As the Veteran has no subjective report of a left shoulder injury during the verified periods of active duty service, and no objective evidence is found of a left shoulder injury during a verified period of active duty service, it is less likely than not that the Veteran's left shoulder AC joint arthritis is related to the Veteran's active duty service. A nexus is not established. Subsequently, in March 2021, VA received an STR labeled "Attachment 3" on page 3 of 29 of a Brief. It shows at the bottom of the page that the Veteran fell landing on the left side of his arm between his chest and ground. This was on July 1, 1991, which corresponds to a notation in Attachment 1. Attachment 1 shows on the far right column a period of "Annual Tour" service from June 19, 1991 to July 3, 1991. In Attachment 4, the Veteran included medical records showing treatment via cold packs and electrical stimulation from 2011. This is not inconsistent with the Veteran's prior lay statements regarding continuity. Here, the Board observes that additional development is necessary in light of the Board's verification of active service, the submission of legibile medical documents, and the contentions in the Veteran's June 2020 Brief. In notable part, a period of serving on his "Annual Tour" was established for the date in question, which corresponds to the STR showing an injury in service. The June 2020 Brief includes an explanation that he has suffered for 30 years since this injury. See June 2020 Brief, p. 2. The Veteran recounts that there was no Line of Duty (LOD) because he was advised to follow up with his primary physician to accommodate his work schedule. In another section, he writes, "If there was an accident on base the EMT's would be called in and you would be advised to contact your local physician. The only time the accident would be noted in your medical records is when you took the information over to the clinic yourself. Which I did." See Brief, p. 7. Indeed, the duty to assist requires that a medical examination be provided when it is "necessary to make a decision on the claim." 38 U.S.C. § 5103A(d)(1). Once again, in Miller v. Wilkie, supra, the Court held that this duty required that an examiner "address the veteran's lay statements to provide the Board with an adequate medical opinion," in part because "medical opinions can inform credibility findings." A medical opinion is adequate when it is based upon consideration of the Veteran's prior medical history and examinations, and also describes the disability in sufficient detail so that the Board's "evaluation of the claimed disability will be a fully informed one." Ardison v. Brown, 6 Vet. App. 405, 407 (1994) (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991)). The Board may reject a medical opinion based on an inaccurate factual basis. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The Veteran has since submitted a clutch of legibile treatment records, received after the November 2020 VA examinations. A supplemental VA examination with medical opinion is necessary. The Veteran need not be re-examined in person unless he specifically requests so or it is deemed necessary by the VA examiner. 2. Entitlement to service connection for a cervical spine disability, characterized as ruptured C4 of the neck is remanded. The Board incorporates its discussion from the section immediately above by reference. By way of background, the Veteran testified at the May 2018 hearing regarding the claimed in service injury that resulted in a ruptured C4 in his neck. The Veteran testified that the injury took place in 1993 during drills as part of Unit Training Assemblies (UTAs): We were in the middle of an ORI exercise for operational readiness and so, we were in battle gear, packs, helmets, face masks, you know, the whole deal. Had a lot of movement, a lot of crawling around, and tried to secure areas. And, the next thing you know, my neck was killing me. It just couldn't have any motion. I couldn't lean it from side to side, severe headache and, by the next morning, taking Tylenol stuff and resting overnight and trying to massage my neck, it had eased. But, from that day forward, I've had, I call it catches in my neck. If I try to turn right or left, it would just sort of stop. And, then I would just have excruciating pain down through my shoulders. The Veteran subsequently sought massages and chiropractic treatment to try to relieve the pressure. He also testified regarding seeing a private treatment provider in October 2000. The Veteran testified that he has worse symptoms in cold weather, which he believes are related to a metal plate being so close to the nerve in his neck. After the May 2018 hearing, the Veteran submitted an excerpt from outstanding private treatment records showing ongoing treatment related to the cervical spine from Dr. E. S. Next, the Veteran was afforded a November 2019 VA neck examination. The VA examiner rendered a positive nexus opinion for direct service connection. The VA examiner reasoned: The veteran's STRs document a herniated C6/7 disc for which he underwent anterior discectomy, osteophyectomy, and allograft fusion on 2/21/2000. He also had a right C6 radiculopathy at that time which resolved with surgery. However, subsequently he has developed a left cervical radiculopathy characterized by numbness and tingling in the left upper extremity which is a complication of his cervical disc disease. Current x-rays dated 11/18/2019 show bilateral neural foraminal stenosis which accounts for the current left radiculopathy. The Board later noted that the rationale does not relate any neck injury resulting in disability to a verified period of active service or ACDUTRA. The rationale does not necessarily dissociate the neck injury from service, but is not conclusive. Moreover, in the June 2020 Brief, the Veteran describes a fall in 1991 and injury in 1995 while working with large equipment. He also references additional evidence. The Brief cites Form 526 from 1995 and he contends that he was "on duty" on April 1 and 2 in 1995. Next, the Veteran was afforded a November 2020 VA neck examination with medical opinion. The VA examiner ultimately rendered a negative nexus opinion. The rationale reads: Veteran reports that he injured his neck in 1995 during training. There is documentation from this time from Emergency Medical Services noting the neck injury and recommendation for follow up. The Veteran does report that he had some chiropractic treatment in the past, however he is unable to obtain all records. There is evidence of a herniated C6-C7 with discectomy and cervical fusion in 2000. The Veteran has evidence of ongoing treatment since that time with continuity of symptoms. There is not evidence of a C4 injury, which appears to be noted in error as there is consistent documentation regarding C6-C7 herniated disc. With consideration of the Veteran's lay statement of onset of neck pain and objective findings, the Veteran's current neck condition is likely related to the neck pain from 1995 that occurred during training. The Veteran has no evidence of a neck injury or neck condition during a period of confirmed active duty service however. The Veteran's last period of active duty service ended 01/08/1986. There is no objective evidence or subjective report of a neck injury or neck condition during a period of active duty service. Therefore, it is less likely than not that the Veteran's current neck disability was incurred in or related to the Veteran's active military service. A nexus is not established. Here, the medical opinion is largely based upon the absence of evidence of a neck injury during a verified period of active service. The rationale does not fully dissociate the current neck disability from past events. New evidence has been received that shows an in service event and that the Veteran served on INACDUTRA in 1995, including from specifically April 1 to April 2, 1995. See March 2020 Brief, Attachment 5, p. 5. Attachment 6 shows a neck injury on a document dated April 2, 1995. Id. at p. 6. Still, there is not a positive nexus opinion. The Veteran should be afforded a supplemental VA examination to determine the relationship between his current neck disability and service. See 38 U.S.C. § 5103A (d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The VA examiner should consider the extensive lay evidence in the Brief, along with private treatment records showing subsequent neck pathology. The consideration of this evidence in forming a nexus opinion is limited to the periods of active service established on the first page of this Remand. The Veteran need not be re-examined in person unless he specifically requests so or it is deemed necessary by the VA examiner. 3. Entitlement to service connection for a heart disability, to include as secondary to diabetes mellitus, type II is remanded. The Board incorporates its discussion from the sections above by reference. By way of background, a Medical Board Report from September 1996 shows that the Veteran suffered a myocardial infarction on March 30, 1996 and underwent cardiac catherization on April 4, 1996. Additional STRs show subsequent related treatment. The Veteran's July 2000 Report of Medical History shows that he endorsed pressure or pain in the chest and heart trouble. He noted a heart attack in 1996. After the May 2018 hearing, the Veteran submitted a June 2018 private medical opinion indicating ongoing private treatment from Dr. A. F. at Marshall Family Medicine. The Board notes that the June 2018 medical opinion does not indicate whether the physician reviewed the claims file. In addition, the opinion is stated in terms of, "It is possible..." The use of the words "possible," "may," or "can be" make a doctor's opinion speculative in nature. See Bostain v. West, 11 Vet. App. 124, 12728 (1998) (quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993)) (medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish medical nexus). Next, the Veteran was afforded a November 2019 VA heart examination. The VA examiner rendered a positive nexus opinion. Once again, the rationale cites STRs documenting an acute myocardial infarction on March 30, 1996. However, active service had not been verified for this date. Pursuant to the August 2018 Remand directives, the VA examiner had been requested to also opine on any secondary relationship between any heart disability and diabetes mellitus. Except as provided in § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310 (a). In other words, the VA examiner was asked to describe any causal relationship between any heart disability and diabetes in clarifying the etiology of any heart disability. Next, as referenced in the June 2020 Brief, the Veteran submitted additional private treatment records along with lay evidence. The Veteran described: The first thing I would like to you review is my AF Form 526 for my attendance in 1996 (attachment 14) March 9 and 10 UTA weekend and April 13 through April 20 I was on my annual tour. I had a myocardial infarction on March 30, 1996. In April my unit was deploying for an exercise. 13 days after my heart attack I was requested to work the Sub Motor Pool to ensure that the exercise went smoothly. The first thing that I did when I reported to the base was to contact the Clinic and let them know that I had a heart attack on March 30. The Veteran cited Attachment 10. Attachment 11 is a September 22, 1996 Medical Board Report from the Air National Guard showing myocardial infarction and cardiac catheterization on March 30, 1996 and April 4, 1996, respectively. The Veteran was medically disqualified for world duty to due to myocardial infarction. Turning to diabetes, the Veteran argued that complications of active but undiagnosed diabetes include heart disease. The Veteran referenced medical journals describing a relationship between prediabetes, diabetes mellitus type II, and heart disease. Following the June 2020 Board Remand, the Veteran was afforded a November 2020 VA heart conditions examination with medical opinion. The VA examiner identified myocardial infarction and coronary artery disease, both with a date of diagnosis of 1996. The VA examiner rendered a negative nexus opinion. The VA examiner reasoned: The Veteran experienced chest pain and was diagnosed with an MI in March 1996. He was evaluated at the hospital and underwent a cath with successful PTCA. Per subjective history and documentation, the Veteran had no evidence or diagnosis of a cardiac condition prior to the MI. March 30, 1996 is not during a period of confirmed active duty service. Therefore, it is less likely than not that the Veteran's current cardiac disabilities were incurred in or otherwise related to his active duty service. A nexus is not established. Turning to secondary service connection, a February 2021 VA addendum medical opinion was obtained. It reads: Although the Veteran's laboratory readings provide clear evidence that a diagnosis of diabetes mellitus was likely present the time of the veteran's acute MI in 1996, there is no evidence that the diabetes had been present for an extended period of time prior to the MI. In the absence of evidence of prolonged elevated blood glucose readings (DM) in the record prior to the Veteran's diagnosis of CAD/MI, it is less likely than not that the Veteran's heart disabilities are a result of diabetes mellitus. Further, the Veteran's heart condition has been stable since the MI in 1996 and denies cardiac related symptoms or concerns. As the condition has remained stable, there is no evidence that his heart disabilities have been aggravated by the diagnosed DM type II. The rationale does not necessarily dissociate heart disability from service, but is not conclusive. New evidence has since been received that shows an event around March 30 to April 13, 1996 by way of STRs. Attachment 10 encompasses several pages and shows a myocardial infarction on or about April 13, 1996. See Brief, Attachment 11, p. 12. By way of a Medical Board Report, the Veteran was referred for final determination due to a myocardial infarction with cardiac catheterization from March 30, 1996 to April 4, 1996. See Brief, Attachment 11, p. 15. The issue remains a nexus, including to a period of verified service. Here, the June 2020 Brief references Attachment 14 as showing service for UTAs in 1996. The Veteran writes about March 9 and 19, and April 13 through 20 as part of his annual tour. See June 2020 Brief, p. 4. However, Attachment 14 on page 19 of 29 is duplicative of Attachment 5, showing service specifically ending on January 8, 1996. Nevertheless, the other attachments and lay evidence establish the Veteran may have reported for duty during those periods. On remand, the RO should collaborate with the Veteran and his representative to verify these claimed dates of service. After obtaining an SPR or DD-214 showing service in March and April 1996, and which specifics dates, the Veteran should be afforded a supplemental VA examination to determine the relationship between any current heart disability and service. See 38 U.S.C. § 5103A (d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The VA examiner should consider the extensive lay evidence in the Brief, along with the contemporaneous documents submitted by the Veteran showing a myocardial infarction in 1996. Turning to secondary service connection and diabetes, the addendum medical opinion does not fully address the Veteran's theory that, "Prior to this I had no knowledge of an elevated glucose level, however an annotation in my records as early as Nov, 30. 1990 indicates I had "elevated blood levels." VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). On remand, such contentions must be addressed in rendering a medical opinion. The consideration of this evidence in forming a nexus opinion is still limited to the periods of active service that can be established. The Veteran need not be re-examined in person unless he specifically requests so or it is deemed necessary by the VA examiner. 4. Entitlement to service connection for diabetes mellitus, type II is remanded. The Board incorporates its discussion from the sections above by reference. By way of background, an STR from Dr. M. W. from March 30, 1996 shows that the Veteran presented with chest pain. It shows that the Veteran had diet controlled diabetes. At the May 2018 hearing, the Veteran testified that in 1990, his STRs showed elevated lab results indicative of diabetes. However, he was not given a formal diagnosis at the time. He asserts that those lab results are sufficient to identify the disease entity in service. Next, the Veteran was afforded a November 2019 VA diabetes examination with medical opinion. The VA examiner rendered a positive nexus opinion for diabetes. The VA examiner remarked, "There is no doubt that the veteran already had diabetes mellitus type II at the time of his heart attack, and subsequently has been treated for diabetes with oral agents." The June 2020 Brief contains additional evidence referencing laboratory readings, Internet links, and lay evidence. He describes that he would have needed a Line of Duty to document diabetes because there was not sick call. At Rickenbacker, Line of Duties were not common for Guard members. He cites prediabetic readings diagnosed as early as 1990 in support of his claim. Next, the Veteran was afforded a November 2020 VA examination with medical opinion. The VA examiner rendered a negative nexus opinion. It reads: The Veteran has a diagnosis of DM type II that was initially made in 1997. Prior to the diagnosis, the Veteran is noted to have evidence in his treatment records of elevated blood glucose readings in 1996 with return of normal readings one month later. There is evidence in the record of elevated lab readings in 1990, however this finding is non-specific and it would be speculative to state the elevated lab was glucose. It should be noted however that neither the elevated lab reading in 1990, nor the elevated blood glucose readings that persisted in 1997, were during periods of active duty service. Therefore, it is less likely than not that the Veteran's DM type II is related to or incurred during active duty service. A nexus is not established. Here, additional contemporaneous treatment records have been obtained since the most recent VA examination. Moreover, the November 2020 VA medical opinion does not address the Veteran's contention in the Brief that "It is not until November 14, 1995 (See Attachment 7 below) that elevated lab results are mentioned in my records again." The Veteran reported that he did not get a copy of the letter in his records and was unaware of the increased lab levels at the time. Upon considering evidence received in March 2021, the page for Attachment 7 contains a label but is blank. This is important inasmuch as notations from 1990, 1995 (to the extent this shows diabetic readings) and later, could establish continuity. A review of these dates was required by the June 2020 Board Remand as part of a consideration of the Veteran's June 2020 Brief. On remand, the Veteran should submit a complete copy of Attachment 7. Afterward, a supplemental VA examination with medical opinion is necessary to determine the relationship between any diabetes and service. See 38 U.S.C. § 5103A (d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006); Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). The VA examiner should consider the extensive lay evidence in the Brief, along with private treatment records and STRs. The consideration of this evidence in forming a nexus opinion is limited to the periods of service established on the first page of this Remand. The Veteran need not be re-examined in person unless he specifically requests so or it is deemed necessary by the VA examiner. The matters are REMANDED for the following action: 1. If the Veteran identifies other evidence, obtain updated copies of the Veteran's VA treatment records, and associate them with the Veteran's claims folder. 2. Send the Veteran a development letter for copies of what he has labeled as Attachments 7 and 14 from in March 12, 2021 corresponding to the Brief. Attachment 7 should reportedly contain November 14, 1995 blood glucose results. Attachment 14 should reportedly contain SPRs or other evidence of service in March and April 1996. Associate legibile copies of these documents with the claims file. 3. After receiving Attachment 14 or any additional SPRs, verify whether the Veteran had any periods of ACDUTRA or INACDUTRA as part of annual training in March and April 1996. See June 2020 Brief. 4. After completing the development above to the extent possible, please schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not necessary) to determine the nature and etiology of any left shoulder disability, claimed as residuals of a left shoulder injury. The claims file should be made available to the VA examiner. The Veteran need not be examined in person unless he specifically requests so or it is deemed necessary by the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The nexus opinion is limited to the periods of service established on the first page of this Remand. Attention is also invited to the Veteran's contentions advanced in the June 2020 Brief. The examiner should provide a rationale for all opinions expressed. 5. After completing the development above to the extent possible, please schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not necessary) to determine the nature and etiology of any cervical spine disability, characterized as ruptured C4 of the neck. The claims file should be made available to the VA examiner. The Veteran need not be examined in person unless he specifically requests so or it is deemed necessary by the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The nexus opinion is limited to the periods of service established on the first page of this Remand. Attention is invited to the Veteran's June 2020 Brief. The examiner should provide a rationale for all opinions expressed. 6. After completing the development above to the extent possible, please schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not necessary) to determine the nature and etiology of any heart disability. The claims file should be made available to the VA examiner. The Veteran need not be examined in person unless he specifically requests so or it is deemed necessary by the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The nexus opinion is limited to the verified periods of active service. The VA examiner should also opine whether any diagnosed heart disability is proximately due to, the result of, or aggravated by the Veteran's diabetes mellitus, type II. Attention is invited to the Veteran's June 2020 Brief. The examiner should provide a rationale for all opinions expressed. 7. After completing the development above to the extent possible, please schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to determine the nature and etiology of any diabetes mellitus. The claims file should be made available to the VA examiner. The Veteran need not be examined in person unless he specifically requests so or it is deemed necessary by the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The nexus opinion is limited to the verified periods of active service. Attention is invited to the contentions in the Veteran's June 2020 Brief regarding pre-diabetic glucose readings. The examiner should provide a rationale for all opinions expressed. 8. After completing the above, and any other necessary development, the claims remaining on appeal must be readjudicated in light of all pertinent evidence and legal authority. If any benefits sought are not granted, issue the Veteran and his representative an appropriate supplemental statement of the case (SSOC). Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Bodi, 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.