Citation Nr: 21041967 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 16-46 872 DATE: July 10, 2021 REMANDED Entitlement to service connection for pancreatitis is remanded. Entitlement to service connection for diabetes mellitus, type 2 is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), depression, and anxiety is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from March 1984 to February 1987. In December 2018 the Board remanded the issues on appeal for further development. The Regional Office (RO) was directed to obtain the Veteran's outstanding Department of Veterans Affairs (VA) and private medical treatment records. The RO was then to schedule the Veteran for a VA examination to determine the nature and etiology of the claimed conditions. Following a November 2019 VA examination, the Veteran was granted service connection for right knee degenerative arthritis and left knee degenerative arthritis. See June 2020 Rating Decision. That decision is considered a full grant of the Veteran's appeals as to those issues. As such, those specific claims are no longer in front of the Board. 1. Entitlement to service connection for pancreatitis is remanded. Following the December 2018 remand, the Veteran was scheduled for a VA examination in November 2019. The request for this examination incorrectly indicated that the Veteran was already service connected for pancreatitis, evaluated at zero percent. The November 2019 examiner stated that the current severity of the Veteran's pancreatitis was a "progression (of his) service-connected disability." This examination did not discuss the etiology of the Veteran's pancreatitis, nor did it discuss the possibility of whether it could have been caused by or aggravated by an acquired psychiatric disorder. The RO requested an addendum opinion regarding the etiology of the Veteran's pancreatitis in June 2020, clarifying that the Veteran was not currently service connected for pancreatitis. To date, this addendum opinion has not been given. Therefore, no VA examiner has opined as to the nature and etiology of the Veteran's pancreatitis as required by the prior remand. 2. Entitlement to service connection for diabetes mellitus, type 2 is remanded. The Veteran underwent a VA examination in November 2019. The request for this examination incorrectly indicated that the Veteran was already service connected for diabetes mellitus, evaluated at zero percent. This examination did not discuss the etiology of the Veteran's diabetes mellitus, nor did it discuss the possibility of whether it could have been caused by or aggravated by the Veteran's pancreatitis. The RO requested an addendum opinion in June 2020. The examiner stated that the Veteran's diabetes mellitus was not directly connected to his active service, as he was first diagnosed in 2011 and the Veteran separated from active service in 1987. The examiner opined that the Veteran's diabetes mellitus was related to hemorrhagic necrotizing pancreatitis complicated by surgeries requiring abdominal drainage and infection. The Veteran's diabetes mellitus appeared within one year following his pancreatitis. Hemorrhagic necrotizing pancreatitis destroyed sufficient beta cells that produce insulin, which resulted in diabetes mellitus. The examiner stated that it is common medical knowledge that necrotizing pancreatitis can lead to diabetes mellitus, type 2. The examiner also stated that the Veteran's medical history is strong to indicate that the Veteran's diabetes mellitus appeared after and was related to the Veteran's pancreatitis. The VA examiner indicated that there was insufficient evidence to determine if the Veteran's diabetes mellitus was aggravated beyond its normal progression by his pancreatitis. As the Veteran's claim for pancreatitis is remanded, and the outcome may impact the adjudication of service connection for diabetes mellitus, type 2, these issues are inextricably intertwined. 3. Entitlement to service connection for headaches is remanded. The Veteran underwent a VA examination in November 2019. At that examination, the examiner did not discuss whether the Veteran's headache disability was directly related to his active service. The examiner stated that there was no relationship between the Veteran's headaches and his pancreatitis or acquired psychiatric disorder, as migraine headaches occur independently. The examiner also stated that the Veteran's headache disability was not aggravated beyond its natural progression by pancreatitis or an acquired psychiatric disorder. At a February 2016 emergency room visit, the Veteran reported that he had headaches when his blood sugar was high as a result of his diabetes. Additionally, a March 2018 private medical examination and opinion indicated that the Veteran's headaches were brought on by stress caused by his depression. The medical provider stated that research has shown patients with mental health disorders are more likely to develop headaches because pain and mood are regulated by the same part of the brain. It was that provider's opinion that the Veteran's depressive disorder and symptoms caused by his pancreatitis more likely than not cause and permanently aggravate his headaches. As the Veteran's claims for pancreatitis and an acquired psychiatric disability are remanded, and the outcome may impact the adjudication of service connection for a headache disability, these issues are inextricably intertwined. 4. Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), depression, and anxiety is remanded. The examiner from the Veteran's November 2019 VA examination determined that it was not at least as likely as not that the Veteran's depressive disorder was incurred in or caused by the Veteran's military service. The examiner relied on the fact that there is no evidence of mental health symptoms or treatment during the Veteran's military service. The medical record reflects that the earliest the Veteran reported experiencing depressive symptoms was in 2003, during the dissolution of his first marriage. He first sought psychiatric treatment in 2013, while dealing with physical health issues. A VA treatment note from October 2013 indicates that the Veteran reported severe depression beginning in at least 2010 following complicated pancreatitis surgery and recovery. Additionally, the November 2019 examiner determined that the Veteran's reported in-service stressor did not meet Criterion A for a diagnosis of PTSD and there were no in-service markers to "substantiate the claimed personal attack." While the Veteran did submit a VA Form 21-0781a, Statement in Support of Claim for PTSD Secondary to Sexual Personal Assault, in October and December 2016, the information contained in those forms indicate that the Veteran's claimed stressor was not based on personal assault. Rather, his claimed stressor was based on strenuous and dangerous conditions during training exercises. However, the VA examiner has not opined as to whether the Veteran's acquired psychiatric disability is caused by or aggravated by his pancreatitis. Dr. HHG offered a private medical opinion, stating that the Veteran's "unspecified depressive disorder more likely than not began in military service, continues to the present and is aggravated by his pancreatitis." See February 2018 Private Medical Opinion. A different private medical practitioner, Dr. H.S., discussing the Veteran's headache disability, opined that the Veteran's depressive disorder and symptoms caused by pancreatitis more likely than not caused and permanently aggravated his headaches. See March 2018 Private Medical Opinion. Therefore, the issue of service connection for an acquired psychiatric disability is inextricably intertwined with the claim of service connection for pancreatitis. The Board sincerely apologizes for this further delay. The matters are REMANDED for the following action: 1. Refer the Veteran's file for an opinion as to the etiology of his pancreatitis. The examiner must opine as to whether it is at least as likely as not (probability of 50 percent) that the Veteran's pancreatitis manifested in service or is otherwise etiologically related to service. The examiner must also opine as to the following: a. Whether it is at least as likely as not that the Veteran's pancreatitis was caused by a psychiatric disability, or b. Whether it is at least as likely as not that the Veteran's pancreatitis has been aggravated by a psychiatric disability. The examiner must specifically discuss the April 2018 private evaluation, as well as the Veteran's reports. 2. Refer the Veteran's file for an opinion as to the etiology of his claimed psychiatric disorder. The examiner must opine as to whether it is at least as likely as not (probability of 50 percent) that the Veteran's psychiatric disorder manifested in service or is otherwise etiologically related to service (he claims strenuous and dangerous conditions during training exercises). The examiner must also opine as to the following: a. Whether it is at least as likely as not that the Veteran's psychiatric disorder was caused by pancreatitis, or b. Whether it is at least as likely as not that the Veteran's psychiatric disorder has been aggravated by pancreatitis. The examiner must specifically discuss the February and April 2018 private evaluations and the article titled, "Depression in headaches: chronification" submitted in September 2020, as well as the Veteran's reports. 3. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issues. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Parker N. Reynolds, 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.