Citation Nr: 21041129 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 15-13 689 DATE: July 8, 2021 REMANDED Service connection for type 2 diabetes mellitus is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from February 1988 to March 1996, March 2002 to August 2002, June 2004 to September 2004, June 2006 to July 2007, January 2008 to August 208, and in July 2012. These matters are before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision. In November 2017, a hearing was held before the undersigned; a transcript of the hearing is associated with the record. In July 2018 and May 2020, the Board remanded this matter for additional development. 1. Service connection for type 2 diabetes mellitus is remanded. Despite the additional and regrettable delay, a remand is required to obtain an addendum medical opinion. After a thorough review of service treatment records associated with the claims file after the last remand, the Board notes several instances within the Veteran's service treatment records that indicate a higher than normal blood glucose range. The December 2020 VA examiner did not address these instances in the medical opinion or evidence review. Further, the examiner appears to focus more on the question of the cause of the Veteran's diabetic neuropathy causes and less on the cause of the Veteran's diabetes mellitus. Therefore, a remand is required in order for the examiner to address these facts. The matters are REMANDED for the following action: 1. Please note that, by law, ALL remanded claims must be processed expeditiously. The Board recognizes that the complex and intertwined nature of the medical questions involved requires significant work on the part of the medical examiner and the AOJ and regrets the need to remand the case to the AOJ. However, the Board is unable to adjudicate the claims until the requested information is provided. Therefore, the Board must ask the VA examiners and the AOJ to ensure compliance with the following directives (that is, full and thoroughly explained answers to each of the questions) to avoid additional delays in adjudication. 2. The AOJ should arrange for a VA medical opinion, with examination or telehealth interview of the Veteran only if deemed necessary by a medical professional, to determine the nature and likely cause of the Veteran's diabetes mellitus. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) For his diabetes mellitus disability, is it at least as likely as not (50% or greater probability) that such disability was either incurred in or otherwise related to the Veteran's military service? Please explain why. In answering the above, the examiner is asked to consider the following: The examiner's attention is drawn to the following records (the following is a brief factual background and not intended to be a substitute for your review of the claims folder): i. A June 1993 lab report indicated the Veteran's blood glucose level was 101 with a normal range indicated of 70-106 mg/DL. There was no indication if the results were fasting. ii. A November 1995 service treatment record lab report indicated the Veteran's blood glucose level was 118 with a normal range indicated of 70-110 mg/DL. There was no indication if the results were fasting. iii. An August 1996 service treatment record noted a blood glucose level of 109 mg/DL, and a normal range was listed as 70-115. There was no indication if the results were fasting. iv. A May 2004 service treatment record noted a fasting blood glucose level of 120 mg/DL, and a normal range was listed as 65-99. v. A March 2010 lab report indicated the Veteran's (fasting: U) blood glucose level was 303 with a normal range of 65-99 mg/DL. vi. An April 2010 service treatment record physical profile noted the Veteran's elevated fasting blood glucose. It also stated the Veteran was not to consume combat rations and that his blood sugar was to be monitored and his medical file was flagged. vii. A November 2010 lab report indicated the Veteran's fasting blood glucose level was 166 with a normal range of 65-99 mg/DL. The record further stated that the Veteran was diagnosed with diabetes mellitus in March 2010 on routine screening and that both his father and mother also had diabetes mellitus. viii. A July 2012 service treatment record listed the Veteran's A1C as 6.1 percent. (b.) Given the above, along with any other medical evidence within the record, is it at least as likely as not (50/50 or better) that the Veteran's elevated blood glucose levels throughout his 20 years of active duty and National Guard service indicate that he was beginning to develop diabetes mellitus much earlier than the March 2010 diagnosis? The examiner should specifically consider and discuss, as necessary, the normal course of diabetes mellitus in light of the intervening period between that period of service and initial diagnosis AND the presentation or severity of his diabetes at the time of initial diagnosis in March 2010. (c.) Further, the Board notes that the Veteran was advised not to consume combat rations after his initial diagnosis of diabetes mellitus. Does this indicate that combat rations could contribute to the development or aggravation of diabetes mellitus? If so, how or how not? Would this have been the case prior to the official diagnosis of diabetes mellitus in March 2010? (d.) The examiner is asked to opine if the evidence that both of the Veteran's parents were also diagnosed with diabetes mellitus plays any role in the Veteran's development of the disease? To what extent would combat rations or military service generally and his dietary provisions during active duty potentially exacerbate his later diagnosis coupled with a family history of diabetes mellitus. The examiner is reminded that, by law, there is no requirement that a veteran be diagnosed in service for a disease to be service connected and a diagnosis may come much later after the development of the disease. A detailed explanation (rationale) is required for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested.) VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Williams, 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.