Citation Nr: 21039992 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 15-35 436 DATE: July 2, 2021 REMANDED Entitlement to service connection for cirrhosis is remanded. Entitlement to service connection for hepatitis C is remanded. Entitlement to service connection for sarcoidosis is remanded. Entitlement to service connection for diabetes mellitus is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from September 1976 to December 1978. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). Procedurally, the Board denied the claim of service connection for cirrhosis and hepatitis C in April 2017, and the Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In July 2018, the Court granted a Joint Motion for Partial Remand (JMR) in which the parties agreed to vacate the April 2017 decision and remand the matters to the Board in order to obtain VA treatment records. In the same April 2017 Board decision, the claim of service connection for sarcoidosis and diabetes mellitus was remanded for development. In March 2018, the Board denied the Veteran's claim of service connection for sarcoidosis and diabetes mellitus. In August 2018, the Board vacated the March 2018 decision based on failure to give the Veteran sufficient time to review the claims file or submit additional evidence before the issuance of the decision. In January 2019, September 2020, and January 2021, the Board remanded the claims of service connection for cirrhosis, hepatitis C, sarcoidosis, and diabetes mellitus for additional development. Most recently, in the January 2021 remand, the Board again remanded the matters to obtain additional medical opinions as to whether service connection is found on a secondary basis due to obesity as an intermediary step. In its reasoning, the Board noted that the October 2020 VA medical opinion did not provide a sufficient rationale for the opinion that the Veteran's service-connected musculoskeletal conditions caused his obesity or that his obesity was aggravated by his service-connected conditions. Walsh v. Wilkie, 32 Vet. App. 300 (2020); see also VAOGCPREC 1-2017. 1. Service connection for cirrhosis. 2. Service connection for hepatitis C. 3. Service connection for sarcoidosis. 4. Service connection for diabetes mellitus. While the Board regrets further delay, additional development in the form of an addendum VA medical opinion is necessary prior to final adjudication. In the latest VA medical opinion obtained in March 2021, the examiner again opined that while musculoskeletal problems could be related to weight gain, this does not necessarily happen, and musculoskeletal problems do not cause obesity. The examiner noted that the Veteran could still very well exercise using his upper body. However, this does not directly address the question posed to the examiner on whether his service-connected musculoskeletal conditions (left ankle disorder and right and left bunionectomies) could have caused the Veteran to become obese, and that in turn, resulted in cirrhosis, hepatitis C, sarcoidosis, and diabetes mellitus. Accordingly, the Board finds remand is again warranted so that an addendum opinion may be provided by a different examiner. In its opinion, the examiner should consider the medical literature submitted by the Veteran on the link between obesity and diabetes mellitus, hepatitis C, and sarcoidosis. Further, a review of the record indicates that in a January 2013 VA 21-4142 Authorization for Release of Information, the Veteran reported seeking treatment at St. Barnabas Hospital for his sarcoidosis. In a May 2017 development letter, the Veteran was asked to fill out a VA Form 21-4142 for this location. However, as the Veteran has already submitted the necessary written authorization, the records should be obtained on remand. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all outstanding treatment records relevant to his claims. Obtain records from St. Barnabas Hospital. The Veteran submitted a VA Form 21-4142 in January 2013. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken, to include notifying the Veteran of the unavailability of the records. 2. Obtain the Veteran's VA treatment records for the period from May 2021 to the present. 3. After records development is completed, obtain a VA addendum opinion from an examiner other than the examiner who provided the October 2020 and March 2021 opinions for the Veteran's cirrhosis, hepatitis C, sarcoidosis, and diabetes mellitus. The claims file should be reviewed by the examiner. The examiner should opine as to the following (causation): (a.) Whether it is at least as likely as not that the Veteran's obesity was caused by his service-connected left ankle disorder and/or service-connected right and left bunionectomies? (b.) If so, is it at least as likely as not that the Veteran's obesity was a substantial factor in causing cirrhosis, hepatitis C, sarcoidosis, and diabetes mellitus? (c.) Whether it is at least as likely as not that the Veteran's cirrhosis, hepatitis C, sarcoidosis, and diabetes mellitus would not have occurred but for his obesity caused by his service-connected left ankle and/or service-connected right and left bunionectomies? The examiner should also opine as to the following (aggravation): (a.) Whether it is at least as likely as not that the Veteran's obesity was aggravated, beyond its natural progression, by his service-connected left ankle and/or service connected right and left bunionectomies? (b.) If so, is it at least as likely as not that the Veteran's weight gain or aggravation of obesity was a substantial factor in causing cirrhosis, hepatitis C, sarcoidosis, and diabetes mellitus? (c.) Whether it is at least as likely as not that the Veteran's cirrhosis, hepatitis C, sarcoidosis, and diabetes mellitus would not have occurred but for his obesity and weight gain aggravated by his service-connected left ankle and/or service-connected right and left bunionectomies? In offering the opinion, the examiner is asked to consider medical literature submitted by the Veteran. The need for an examination is left to the discretion of the examiner. The examiner must provide a complete rationale for his or her opinion(s) in the examination report. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Mathew 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.