Citation Nr: 21030974 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 15-14 497 DATE: May 20, 2021 REMANDED Entitlement to service connection for type 1 diabetes is remanded. Entitlement to service connection for loss of pancreatic function, to include as secondary to diabetes, is remanded. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to diabetes, is remanded. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to diabetes, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1996 to January 1997 and October 2003 to February 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned in June 2018. This matter was previously remanded by the Board in October 2018. The case has been returned to the Board at this time for further appellate review. 1. Entitlement to service connection for type 1 diabetes is remanded. This matter was remanded in October 2018, in part, to obtain a VA medical opinion from an endocrinologist, or other appropriate medical specialist, with respect to the Veteran's service connection claim for type 1 diabetes. In this regard, the VA examiner was directed to opine as to whether it was at least as likely as not that the Veteran's type 1 diabetes had its onset in and/or is otherwise etiologically related to his service, or manifested within one year of service, to include whether it is at least as likely as not that the Veteran's type 1 diabetes was caused by or is otherwise related to the anthrax vaccine he received in service. The VA examiner was asked to discuss a July 2018 private medical opinion, the October 1999 testimony of a physician before Congress, and a 2001 medical article submitted by the Veteran. A VA opinion was obtained in October 2019 from a general medicine practitioner. The VA examiner noted that (1) the Veteran left the military in 2005 and was not diagnosed with diabetes until February 2007, and (2) notwithstanding the testimony of Dr. Claussen, the Institute of Medicine did a retrospective study in 2007 and noted no relationship between anthrax and type 1 diabetes. The VA examiner then opined that it is less likely than not that anthrax caused the Veteran's type 1 diabetes. The VA examiner provided no other rationale. The Board finds that the October 2019 VA opinion does not comply with the Board's prior remand directives for the following reasons. First, the VA examiner did not clearly opine as to whether the Veteran's type 1 diabetes is otherwise etiologically related to his active service, a particularly important question given that he was diagnosed within two years of leaving active duty service and has indicated he believed he was manifesting symptoms of type 1 diabetes within a year of leaving active duty service. Secondly, the VA examiner did not address the July 2018 private medical opinion or the 2001 medical article submitted by the Veteran. Accordingly, remand for a new VA opinion is necessary to ensure compliance with the Board's prior remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The Board also notes that remand is warranted because the October 2019 VA opinion does not provide a sufficient rationale for the opinions provided. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (probative value of a medical opinion is derived from it being factually accurate, fully articulated, and soundly reasoned). 2. Entitlement to service connection for loss of pancreatic function, to include as secondary to diabetes, is remanded. 3. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to diabetes, is remanded. 4. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to diabetes, is remanded. The Veteran asserts that he has loss of pancreatic function and peripheral neuropathy of the bilateral lower extremities due to his diabetes. As the outcome of the Veteran's service connection claims for loss of pancreatic function and peripheral neuropathy of the bilateral lower extremities are dependent on whether service connection is established for diabetes, these claims are inextricably intertwined, and thus are remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any appellate review on the other claim meaningless and a waste of judicial resources, the two claims are inextricably intertwined). The matters are REMANDED for the following action: Obtain an opinion with an endocrinologist, or other appropriate medical specialist, who has not previously opined about the Veteran's claim to determine the nature and etiology of the Veteran's type 1 diabetes. If the selected clinician determines that an examination is necessary to respond to this request, such examination should be scheduled. Following review of the claims file, and examination of the Veteran if deemed necessary, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's type 1 diabetes had its onset in and/or is otherwise etiologically related to his active service, including his in-service anthrax vaccine, or manifested within one year of service. In providing such opinion, it would be helpful if the medical specialist referenced medical studies and/or medical articles as part of his or her opinion. The medical specialist must also discuss the (1) Veteran's December 2008 VA treatment record which notes that the Veteran's anthrax vaccine is a suspected trigger for his diabetes, (2) July 2018 private medical opinion, (3) October 1999 physician's testimony before Congress, and (4) July 2002 and December 2004 medical articles written by Dr. Nass and submitted by the Veteran. (Continued on the next page) The examiner is advised that the Veteran is competent to report his symptoms capable of lay observation, and such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide a reason for doing so. The Veteran's report of symptoms capable of lay observation cannot be dismissed solely on the basis that they are not recorded in contemporaneous treatment records. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If an opinion cannot be given without resorting to speculation, the medical specialist should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the medical specialist (does not have the knowledge or training). M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Elias, 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.