Citation Nr: 18132243
Decision Date: 09/06/18	Archive Date: 09/06/18

DOCKET NO. 16-04 869
DATE:	September 6, 2018
Entitlement to service connection for diabetes mellitus.
Entitlement to service connection for peripheral neuropathy of the lower and upper extremities, as secondary to diabetes mellitus.
The Veteran served on active duty from November 1965 to November 1967.
This matter is before the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO).
The Board finds that a VA medical examination is necessary to decide the claims as the evidence of record does not contain sufficient competent medical evidence to decide the claim.  VA’s duty to assist includes providing a medical examination when is necessary to make a decision on a claim.  38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4).  Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or symptoms of disability, (2) establishes that the veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability.  38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006).
Although the Veteran underwent a VA diabetes examination in August 2013, the results from that examination appear to be in conflict.  The VA examiner appears to indicate that the Veteran did not have diabetes, rather, only had impaired fasting glucose.  But the examiner later found that there was diabetic peripheral neuropathy.  The Board also observes that it appears that the determination as to the Veteran’s diabetes diagnosis was based in large part on laboratory results from 2009 and 2010 as opposed to contemporaneous findings.  Based on the foregoing, the Board finds that the Veteran should be scheduled for a VA examination.
The matters are REMANDED for the following action:
1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment on and after October 22, 2014.  If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file.  Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile.  The non-existence or unavailability of such records must be verified and this should be documented for the record.  Required notice must be provided to the Veteran and his representative (if any).
2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records.  Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file.  All information obtained must be made part of the file.  All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative (if any).
3.  After any additional records are associated with the claims file, provide the Veteran with the appropriate examination to determine whether he has diabetes mellitus.  The claims file must be made available to and reviewed by the examiner.  Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis.  An explanation for all opinions expressed must be provided.
The examiner must state whether the Veteran has diabetes mellitus.  In doing so, the examiner is asked to state the basis for the determination provided and should reference contemporaneous laboratory findings.  The examiner is advised that the sole purpose of this examination is to determine whether the Veteran has diabetes mellitus, and an etiology determination is not being requested.
If it is determined that the Veteran does not have a current diagnosis of diabetes, the examiner is asked to state whether the Veteran has diabetic peripheral neuropathy of the lower or upper extremities, even in the midst of not carrying a diagnosis of diabetes itself.
4.  Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims.  38 C.F.R. §§ 3.158, 3.655 (2018).  In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address.  It must also be indicated whether any notice that was sent was returned as undeliverable.
Veterans Law Judge
Board of Veterans’ Appeals

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