Citation Nr: 21040278 Decision Date: 07/03/21 Archive Date: 07/03/21 DOCKET NO. 15-15 534 DATE: July 3, 2021 REMANDED Service connection for diabetes mellitus type I ("diabetes") is remanded. REASONS FOR REMAND The Veteran served on active duty from February 2002 to February 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a December 2016 Board hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is associated with the electronic claims file. The Board remanded this matter most recently in January 2021 for missing private treatment records and an addendum medical opinion. The RO provided the Veteran with releases for the pertinent outstanding private treatment records, and, when the Veteran did not return any releases or provide any other records in support of his claims, scheduled and obtained the requested examination and addendum opinion. Unfortunately, the Board finds that the obtained addendum opinion is inadequate, and another remand is necessary. See Stegall v. West, 11 Vet. App. 268 (1998). The January 2021 remand instructions requested that a VA examiner consider the Veteran's service treatment records, with specific emphasis placed on notations in his records regarding glucose levels, diabetes checks, family history reports, triglyceride and A1C levels, and sudden weight gain. After considering these records and discussing pertinent evidence, the examiner was asked to determine the nature and etiology of the Veteran's diabetes and then opine as to whether it is at least as likely as not that (1) the Veteran's diabetes manifested in or is otherwise etiologically related to service, and (2) the Veteran's diabetes was caused by the weight management program he underwent in service, including taking any supplements. The March 2021 examiner marked that he reviewed all available records and findings, and concluded that the Veteran's diabetes was less likely than not incurred in or caused by the Veteran's claimed in-service injury, event, or illness. In making this conclusion, the examiner noted that the Veteran was diagnosed with diabetes in service and agreed with a previous VA opinion determining that the Veteran's diabetes was likely due to his lifestyle and eating habits. The examiner also discussed the Veteran's contention that his diabetes was caused by his in-service use of ephedra, noting that because ephedra is a common weight loss supplement, it is unlikely to cause weight gain resulting in diabetes and does not have a side effect of causing diabetes. The examiner did not address any of the service treatment records relevant to diabetes, such as lab results and prior discussions of diabetes by the Veteran and his in-service providers, as requested by the remand. The Board finds that the March 2021 VA opinion is inadequate. The examiner incorrectly stated the Veteran was diagnosed with diabetes in service, when his prior statements and VA examinations indicate that his earliest official diabetes diagnosis was in 2010, five years post-service. Additionally, the examiner's failure to address the Veteran's service treatment records, particularly those including lab results relevant to a diabetes diagnosis, indicates that this opinion was not fully informed as it did not reflect knowledge of the relevant facts of this case. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) ("a thorough medical examination is one that 'takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one.'"). While the Board sincerely regrets the additional delay, another remand is necessary to afford the Veteran due process of law. Accordingly, the matters are again remanded to obtain an adequate opinion and to ensure compliance with the Board's previous remand directives. Stegall, 11 Vet. App. at 271; Barr, 21 Vet. App. at 311. Since it is necessary to remand the case again, the Board will give the Veteran another opportunity to complete releases authorizing the VA to request various private treatment records that he has previously referenced. However, the Board notes that "[t]he duty to assist is not always a one-way street" and if the Veteran desires help with his claims, he must cooperate with VA's efforts to assist him. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Veteran is advised that if he does not sign releases for these private records, or submit them himself to VA, then the evidence will remain incomplete. The matter is REMANDED for the following action: 1. Request the private medical records the Veteran referenced from private endocrinologists and dietary nutritionists. After securing the necessary releases, attempt to obtain and associate those identified treatment records with the claims file. If any identified records cannot be obtained and further attempts would be futile, such should be noted in the claims file and the Veteran should be notified so that he can make an attempt to obtain those records. 2. Return the Veteran's claims file to the March 2021 VA examiner (or another VA examiner if that person is no longer available) for an addendum medical opinion. The examiner should review the entire claims file and expressly consider the following service treatment records, prior to rendering an opinion: (a.) August 2002, his blood test results indicated his glucose level was at 98 and he was put in the weight loss program; (b.) September 2003, he had a diabetes check and was placed on a lower calorie and high fiber diet; (c.) August 2004, his active medical conditions included obesity and dietary surveillance and counseling; (d.) November 2004, he reported his mother had a history of diabetes; (e.) February 2005, his triglyceride levels were 66, and his HGB A1C level was 5.7 with the listed interpretation as "diabetic patients in good control may have Hgb A1C values in the normal range. When using HbA1C to monitor the diabetic patient, results must be interpreted on an individual basis." (f.) September 2005, he gained 16 pounds in one week; (g.) January 2006, his endocrine system was within normal limits; (h.) His diagnosis of uncontrolled diabetes in 2010, as testified to and noted in his VA treatment records; (i.) The April 2015 statement by the Veteran that during his ongoing weight loss program in the military, he was eventually "asked to obtain these over the counter weight loss aids (with ephedra ingredients) and continue to perform physical fitness routines several times a day" and that following service, he "began to gain weight at a significant rate causing health complications." (j.) The December 2016 sworn testimony where the Veteran stated he had weight problems during service and that he took ephedra and Hydroxycut to help lose the weight. He testified having jitters and rapid heart rate and sweating after taking these pills. He stated he requested the blood work to be tested as his mother had gestational diabetes and other people with a similar weight issue in service had tested positive for diabetes after leaving service. He stated he had had symptoms such as thirst, fluctuations in weight, and frequent urination for years prior to the 2010 diagnosis. (k.) The December 2016 sworn testimony where the Veteran stated that he has been told by dieticians and endocrinologists have told him that the extreme nature of his routine during service could have caused metabolic issues that resulted in diabetes, and that he gained about 100 pounds within the first year post-service. After expressly considering the above-mentioned service treatment records and lay statements, the examiner must opine: whether is at least as likely as not that the Veteran's diabetes mellitus type I had its initial onset in service or is otherwise etiologically related to the Veteran's active service? NOTE: The 2021 opinion incorrectly stated the Veteran was diagnosed during service with diabetes; such a diagnosis was not provided until 2010, five years post-service. The opinion should be provided with a full supporting rationale based on the examiner's clinical experience, medical expertise, and established medical principles. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Tierno 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.