Citation Nr: 21027200 Decision Date: 05/05/21 Archive Date: 05/05/21 DOCKET NO. 13-10 403 DATE: May 5, 2021 REMANDED Entitlement to service connection for type II diabetes mellitus (diabetes), for the purpose of accrued benefits, is remanded. Entitlement to service connection for a neurodegenerative disorder, to include amyotrophic lateral sclerosis (ALS) and progressive supranuclear palsy (PSP), for the purpose of accrued benefits, is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depression, for the purpose of accrued benefits, is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1965 to June 1968. He died in August 2013. The Appellant is the Veteran's surviving spouse. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2010 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2017, the Board denied the claims of entitlement to service connection for type II diabetes mellitus, a neurodegenerative disorder, and an acquired psychiatric disorder, to include PTSD and depression. The Appellant appealed the Board's denials to the United States Court of Appeals for Veterans Claims (Court). In a May 2019 Memorandum Decision, the Court vacated the Board's denials of service connection for the above claims. The Court found the Board failed to provide adequate reasons or bases for the finding that additional medical evidence of record outweighed the Appellant's positive medical opinions. Additionally, the Court found the Board failed to provide adequate reasons or bases for the determination that VA fulfilled its duty to assist without providing a VA medical opinion to the Appellant. In October 2019 and September 2020, the Board remanded the Appellant's claims for additional development, to include additional VA examinations and medical opinions. The case has since been returned to the Board for appellate review. While the Board regrets further delay, another remand is necessary to provide the Appellant with necessary medical opinions, and to ensure substantial compliance with the September 2020 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for diabetes, for the purpose of accrued benefits, is remanded. Pursuant to the September 2020 Board remand, a VA opinion was obtained in November 2020. Critically, the examiner noted that this was an in-person examination, which is the basis for a remand for clarification, as the Veteran is deceased. While the Board acknowledges the examiner's brief address of causation of diabetes by exposure to hazardous fumes, in rendering a negative opinion the examiner did not opine on the Appellant's contention that the Veteran's diabetes were related to service, as specifically requested in the Board remand. See Stegall, supra. To that end, the Board notes that making a conclusory statement that there is no literature on the matter, on its own, will render the opinion insufficient. Additionally, if the examiner feels the favorable nexus opinions of record are inadequate, the examiner should provide his or her reasoning for such. 2. Entitlement to service connection for a neurodegenerative disorder, to include ALS and PSP, for the purpose of accrued benefits, is remanded. Pursuant to the September 2020 Board remand, a VA opinion was obtained in November 2020. Critically, the examiner noted that this was an in-person examination, which is a basis for a remand for clarification, as the Veteran is deceased. As to the substance of the November 2020 VA opinion, the examiner essentially provided a favorable opinion and opined that "exposure to manganese in welding fumes can cause parkinsonian neurological disorders." The RO requested an addendum opinion as the opinion was not on point, confusing, and therefore inconclusive, which will be addressed further below. The Board agrees. It is well established that medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. An addendum VA opinion was obtained in January 2021 by the same examiner who provided the November 2020 opinion. The Board finds this opinion inadequate as well, for largely the same reasons as the November 2020 opinion. It is still unclear if the diagnoses the Veteran was correctly assessed with are attributed to his claimed in-service event of burning an unknown chemical substance and exposure to its fumes. To that end, the record does not support that the Veteran was a welder and would have been exposed to manganese in this manner, or that he was diagnosed with Parkinson's disease, as used as the basis of the examiner's favorable opinion; rather his treating physicians initially thought he had Parkinson's disease (amongst a myriad of other diagnoses) until he was ultimately given the diagnosis of PSP, and his amended death certificate reveals an additional diagnosis of bulbar ALS. As such, clarification is needed on remand. Barr v. Nicholson, 21 Vet. App. 303, 310-11 (2007). 3. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and depression, for the purpose of accrued benefits, is remanded. Pursuant to the October 2019 Board remand, VA provided a medical opinion as to the entitlement to service connection for an acquired psychiatric disorder, to include as secondary to the claimed medical conditions. In December 2019, the VA examiner reviewed the Veteran's claims file and provided the opinion that the Veteran's diagnosed depression was at least as likely as not proximately due to or the result of the Veteran's neurodegenerative disorders. Additionally, the VA examiner noted the Veteran's type II diabetes could likely have exacerbated and contributed to the Veteran's depressive disorder. With the December 2019 VA medical opinion identifying the nexus relationship between the Veteran's depression and the claimed medical conditions, awards for service connection for the Veteran's diabetes and neurodegenerative disorders may provide the basis for entitlement to service connection for the Veteran's depression. As such, the Board finds the issues are inextricably intertwined, and a remand is necessary to adjudicate the above claims together. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Send the claims file to an appropriate examiner for an opinion on the etiology of the Veteran's type II diabetes mellitus. The claims file should be reviewed in conjunction with the examination. A copy of this remand should be made available to the examiner. Following a review of the record, the examiner is requested to 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 mellitus, type II, occurred in or was otherwise etiologically related to service, to include exposure to hazardous fumes. In answering this question if the examiner does not find that the Veteran's diabetes was incurred due to exposure to hazardous fumes, the examiner must still opine as to whether or not his diabetes was directly related to service. Please also address the favorable medical opinions of record. For purposes of this examination and opinion, the examiner must consider the full record, to include the Veteran's VA and private medical treatment records, and the opinion should reflect such consideration. A complete rationale must be provided for all opinions expressed and must not be based solely on the lack of any in-service records. If for any reason the examiner is unable to provide a medical opinion, he or she should provide a rationale for that conclusion (e.g. whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge). 2. Send the claims file to an appropriate examiner for an opinion on the etiology of the Veteran's neurodegenerative disorders, to include ALS and PSP. The claims file should be reviewed in conjunction with the examination. A copy of this remand should be made available to the examiner. Following a review of the record, the examiner should identify any neurodegenerative disorder(s) and provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any such neurodegenerative disorder(s) occurred in or was otherwise etiologically related to service, to include exposure to hazardous fumes. In addition to answering the above question, please opine as to: (a.) Whether ALS or PSP is a type of Parkinsonism? And if not, could exposure to manganese in welding fumes cause ALS or PSP? (b.) Whether manganese exposure can come from fumes from burning barrels of an unknown chemical? (c.) Whether it is at least as likely as not that the etiology of impairments including dysphagia, dysarthria, incontinence of bladder, incontinence of bowel at times, and need for a feeding tube came from ALS or PSP? For purposes of this examination and opinion, the examiner must consider all VA and private medical treatment records, and the opinion should reflect such consideration. Specifically, the examiner must address records containing private medical opinions received into the record August 11, 2017, to include: (a.) The December 1, 2012 letter from the Clinical Director of the University of North Carolina Department of Neurology, Movement Disorders Clinic; (b.) The December 20, 2012 letter from Carolina Geriatrics, PA; and (c.) Private medical records from Cape Fear Heart Associates, dated June 10, 2011. A clearly stated rationale for any opinion offered should be provided and must not be based solely on the lack of any in-service records. T. Berry Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. J. Rogers, Associate 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.