Citation Nr: 21027245 Decision Date: 05/05/21 Archive Date: 05/05/21 DOCKET NO. 15-34 850 DATE: May 5, 2021 REMANDED Service connection diabetes mellitus, type II (diabetes), is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from February 1972 until his honorable retirement in February 1992. This appeal is being treated expeditiously on the Board of Veterans' Appeals' (Board) docket pursuant to 38 U.S.C. §§ 5109B, 7112 and 38 C.F.R. § 20.902(d). This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2015 decision by the St. Petersburg, Florida, Regional Office (RO) of the United States Department of Veterans Affairs (VA). In March 2017 the Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ). In an April 2020 decision, the Board denied the Veteran's claim. The Veteran subsequently appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). Based on a Joint Motion to Remand (JMR) submitted by the parties, the Court entered an order in December 2020 vacating the Board's decision in full and remanding the matter to the Board for readjudication. Within the JMR, the parties stipulated the Board first erred by not addressing the Veteran's lay statements contained in his December 2014 Statement in Support of Claim in which he said he was exposed to Agent Orange while handling pallets during his active service. Second, the Board erred when it did not address his March 2017 Board hearing testimony that he had to do perimeter duty work once or twice a month at the Royal Thai Air Force Base where he was stationed. Also included within the JMR is the Veteran's assertion that VA did not fulfill its duty to assist, but this was not a point to which VA's General Counsel stipulated. The Veteran asserted VA did not obtain outstanding private medical records based on his March 2017 Board Hearing testimony. The Board has reviewed the March 2017 hearing testimony and finds his testimony does not indicate outstanding private medical records existed. Regardless, based on the Veteran's assertions in his April 2021 appellate brief submitted to the Board following remand from the Court, the Board will still instruct the RO to attempt to locate the outstanding private medial records. Finally, the Board observes the Veteran has asserted in a portion of his appellate brief before the Court that the March 2019 VA-contracted examiner did not address the Veteran's lay statements as part of the medical opinion. See Dalton v. Peake, 21 Vet. App. 23, 3940 (2007) (a medical opinion is inadequate if it does not take into account a veteran's reports of symptoms and history, even if recorded in the course of the examination). In addition, the Veteran points out that the examiner initially reported elevated HgbA1C (glycosylated hemoglobin) in 2002 during the examination, but within his medical opinion stated the initial reported elevation of HgbA1C occurred in 2005. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) ("An opinion based on an inaccurate factual premise has no probative value."). Thus, remand is necessary to an addendum opinion. Accordingly, the matter is REMANDED for the following actions: 1. Obtain any of the Veteran's outstanding VA medical records and associate them with the claims file. 2. Send appropriate correspondence to the Veteran asking his to identify and authorize release of any relevant medical records from: (a.) Heritage Valley Medical System; (b.) Sewickley Valley Hospital; and (c.) Any other private treatment received for his diabetes mellitus, type II, not already of record. Reasonable attempts must be made to obtain relevant private medical records. 3. Following completion of directives #1 and #2, obtain an addendum opinion from the March 2019 VA-contracted examiner, or another appropriately qualified clinician if that examiner is unavailable, to provide an opinion addressing the onset and etiology of the Veteran's diabetes mellitus, type II. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. If the examiner decides an examination is necessary, then one shall be provided. The examiner is asked to provide an opinion regarding whether it is at least as likely as not (50 percent probability or more) that the Veteran's diabetes mellitus, type II, had its onset in or is otherwise etiologically related to an in-service event, injury, or disease. In rending his or her opinion, the examiner should consider and, if deemed relevant, address the following, in addition to any other relevant evidence: (a.) An April 1991 service treatment record laboratory test result that shows a glucose level of 116 mg/dL where the reference level was 70 to 110. (b.) The Veteran's March 2017 testimony before the Board that in January or February 1993, within one year of his separation from service, he went to the hospital because he was passing out due to high blood sugar and had frequent urination. March 2017 Board Hearing Transcript, at 4. (c.) A June 1996 private medical record that includes blood test results and shows glucose levels of 381 mg/dL. (d.) The Veteran's testimony that he was not formally diagnosed with diabetes mellitus until 1999. March 2017 Board Hearing Transcript, at 3. The examiner is reminded to consider the Veteran's lay statements regarding the nature and onset of his disability, including any evidence concerning continuity of symptomatology, as he is legally permitted to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran's assertion of a diabetes mellitus, type II, in service or the assertion that an in-service event, injury, or illness led to development of the disease. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinion(s), including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. If the examiner relies on medical treatises, the examiner should identify the treatises. If a requested opinion cannot be provided without resorting to speculation, the examiner should so state and explain why an opinion cannot be provided without resorting to speculation. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to the particular question(s). M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. F. Sawka, 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.