Citation Nr: 18154220
Decision Date: 11/29/18	Archive Date: 11/29/18

DOCKET NO. 07-40 008
DATE:	November 29, 2018
ORDER
Entitlement to service connection for a right arm disorder, claimed as numbness and tingling, is denied.
Entitlement to service connection for a neck disorder is denied.
Entitlement to service connection for a back disorder is denied.
Entitlement to service connection for an acquired psychiatric disorder, claimed as depression, to include as secondary to back disorder, is denied.
Entitlement to a compensable initial rating prior to June 14, 2008, and a rating in excess of 30 percent thereafter for headaches is denied.
REMANDED
Entitlement to service connection for a disorder manifested by low energy, to include chronic fatigue syndrome, and to include as secondary to type II diabetes mellitus and an acquired psychiatric disorder, is remanded.
Entitlement to service connection for type II diabetes mellitus, to include as secondary to service-connected disability, is remanded.
Entitlement to service connection for a heart disorder, to include as secondary to type II diabetes mellitus, hypertension, and/or headaches, is remanded.
Entitlement to a total disability rating based on individual unemployability due to service-connected disability is remanded.
FINDINGS OF FACT
1.  The preponderance of the evidence does not demonstrate a right arm disorder had its onset in service or is due to a disease, event, or injury in service.
2.  The preponderance of the evidence does not demonstrate that a neck disorder had its onset in service or is due to a disease, event, or injury in service.
3.  The preponderance of the evidence does not demonstrate that a back disorder had its onset in service or is due to a disease, event, or injury in service. 
4. The preponderance of the evidence does not demonstrate that an acquired psychiatric disorder had its onset in service, is due to a disease, event, or injury in service, or is secondary to a service-connected disability.
5.  Prior to June 14, 2008, the Veteran’s headaches were not manifested by characteristic prostrating attacks occurring on an average of once in 2 months over the last several months.
6.  On and after June 14, 2008, the Veteran’s headaches have not manifested with symptoms that approximate very frequent and prostrating and prolonged attacks productive of severe economic inadaptability.
CONCLUSIONS OF LAW
1.  The criteria for service connection for a right arm disorder, claimed as numbness and tingling, have not been met.  38 U.S.C. §§ 1110, 1111, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a)-(b), (d), 3.307, 3.309(a).
2.  The criteria for service connection for a neck disorder have not been met.  38 U.S.C. §§ 1110, 1111, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a)-(b), (d), 3.307, 3.309(a).
3.  The criteria for service connection for a back disorder have not been met.  38 U.S.C. §§ 1110, 1111, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a)-(b), (d), 3.307, 3.309(a).
4. The criteria for service connection for an acquired psychiatric disorder, claimed as depression, to include as secondary to back disorder, have not been met.  38 U.S.C. §§ 1110, 1111, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a)-(b), (d), 3.307, 3.309(a).
5.  The criteria for a compensable initial rating prior to June 14, 2008, and in excess of 30 percent thereafter for headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.124a, Diagnostic Code (DC) 8100. 
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran served on active duty from January 1974 to January 1976, with additional service in the National Guard.  The record does not verify service in the Republic of Vietnam.  These matters come before the Board of Veterans’ Appeals (Board) on appeal of an October 2006 rating decision of a Department of Veterans Affairs’ (VA) Regional Office.  
In February 2010, the Veteran did not appear for a scheduled Board hearing.  The Veteran has not requested an additional hearing or provided good cause for his failure to attend.  Accordingly, his hearing request is deemed withdrawn.  38 C.F.R. § 20.704(d).  
These claims were previously remanded by the Board in October 2011 and July 2016.
In April 2018, the Board requested a medical opinion concerning the appeal for a back disorder, neck disorder, and right arm disorder.  The Board received the requested opinion and sent the opinion to the Veteran for review.  The record shows the opinion and notification were returned as undeliverable.  As the record shows the documents were sent to the Veteran’s address of record, the Board finds proper procedure was followed and appellate review may proceed.

Service Connection
Service connection will be granted if the evidence demonstrates that a current disorder resulted from an injury or disease incurred in or aggravated by active service, even if the disorder was initially diagnosed after service.  38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 
Certain chronic diseases will be presumed related to service if they were noted as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if continuity of the same symptomatology has existed since service, with no intervening cause.  38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a).
1.  Entitlement to service connection for a right arm disorder, claimed as numbness and tingling
The Veteran contends that he is entitled to service connection for right arm problems that he believes had their onset during service.
Service treatment records are silent as to complaints, treatment, or diagnosis of the right arm.  An October 1975 clinical evaluation for separation noted no abnormality of the upper extremities; the Veteran indicated good health in the related report of medical history.  
The post-service treatment records show that the Veteran complained of shoulder and arm pain decades after service.  In May 2000, the Veteran reported neck pain radiating down to the right arm and shoulder with onset after a November 1999 motor vehicle accident.  At the time, the Veteran was given a diagnosis of right shoulder girdle sprain and strain.  In September 2006, the Veteran reported radicular pain in the arm with a diagnostic assessment of cervical radiculopathy.  In February 2007, the Veteran complained of right arm pain radiating from the neck, and right shoulder pain which had begun one month prior.  In March 2007, the Veteran underwent nerve conduction study and electromyography of the upper extremities. The study showed abnormalities with chronic ulnar neuropathy of the right elbow.  In October 2007, the Veteran followed up for right shoulder pain with complaint of radiating numbness, pain and weakness; the impression was rotator cuff issues without traumatic onset and possible cervical spine component.  A June 2008 VA treatment record shows the Veteran reported right elbow pain after a 1997 injury.  
In May 2018, the Board obtained a medical opinion from a neurosurgeon.  The neurosurgeon found the evidence of record did not indicate that right arm pain or cervical radiculopathy started or was related to any well-documented injury sustained in service.  Rather, the neurosurgeon indicated that there were multiple post-service events which would be more likely than not the cause of the Veteran’s condition.  The neurosurgeon also noted that the condition is one typically related to age-related changes or direct trauma and not related to any strain that may have occurred in service.
Based on this evidence, the Board finds service connection for a right arm disorder is not warranted.  Here, the service treatment records are negative for complaints of, treatment for, or a diagnosis of a disorder related to the right arm.  In addition, the record does not include a competent opinion linking a current right arm disorder to service.  In this respect, the Board finds probative the May 2018 medical opinion as it was based on a review of the evidence, considered the Veteran’s lay statements, and provided adequate rationale.  
In sum, the evidence weighs against a nexus between a current right arm disorder and active military service.  Accordingly, the benefit of the doubt doctrine does not apply, and service connection is not warranted.  See 38 U.S.C. §5107 (2012); 38 C.F.R. §3.102 (2016); Gilbert v. Derwinski, 1 Vet. App.49, 55 (1990).  
2.  Entitlement to service connection for a back and/or neck disorder
The Veteran asserts his current back and neck problems began during service.  See April 2006 VA 21-4138 and June 2006 Correspondence.  In a March 2007 written statement, the Veteran reported his job for sixteen months in Germany was to put up antennas for communication.  He reported that these antennas were 45 to 110 feet in height and that the work was taxing on the low back and cervical area of the spine.  
During service the Veteran was seen with complaints of low back pain after heavy lifting.  See March 1975 service treatment records.  The impression was musculoskeletal low back pain.  He was treated with Valium and a heating pad, and placed on a two-week profile for no heavy lifting.  On his service separation examination in October 1975, the Veteran denied recurrent back pain, and the examination of the spine was noted as normal. 
National Guard records show that the Veteran had surgery in a private hospital in March 1978 for an unspecified condition.  He also had physical therapy and was to avoid heavy lifting for 72 hours in June 1979 for an unspecified condition.  The Veteran has alleged that these references are to back and neck injuries; however, he did not provide releases for VA to attempt to obtain the records.
Post-service, lumbar sprain was noted in February 1992 and September 1994.  In March 1999 X-ray noted mild degenerative arthritis changes of the lumbar spine, and MRI showed disc herniation/protrusion at L5-S1 and mild disc bulge at L4-5.  In December 1999, the Veteran was treated following a motor vehicle accident in November 1999.  The private treating physician noted acute cervical and thoracic strain and sprain; acute lumbosacral sprain and strain; rule out lumbar radiculopathy; and aggravation of herniated nucleus pulposus, lumbar spine.  A February 2000 private treatment record noted a back injury while working for the police. 
In October 2001, the Veteran was again treated for neck and back pain following a motor vehicle accident.  A March 2002 MRI of the cervical spine noted annular bulging and facet and uncovertebral hypertrophy superimposed on developmental narrowing of the cervical spine, most prominent at C5-6 and C6-7.  In May 2006 correspondence with the Social Security Administration, the Veteran indicated that he was receiving disability retirement benefits from the City of Philadelphia based on a 1987 injury sustained while working as a police officer.  Other references in the record indicate that this was a back injury.  The Veteran did not provide releases for VA to attempt to obtain the employment records from the City of Philadelphia.
A September 2006 treatment record noted degenerative joint disease of the cervical spine with neuropathy.  MRI of the C-spine in December 2006 showed mild degenerative disc disease at C5- C6 and C6-C7.  There was mild spinal stenosis and mild bilateral neuroforaminal narrowing at C5-C6.  
In March 2007, EMG and NCS testing noted electrophysiologic evidence of chronic ulnar neuropathy of the right elbow; there was no evidence of peripheral neuropathy, brachial plexopathy, or radiculopathy.
A January 2017 VA examination noted the Veteran reported a history of low back and neck pain since lifting heavy objects during service in 1974.  The examiner noted diagnoses of degenerative arthritis and intervertebral disc syndrome of the lumbar spine, and degenerative arthritis of the cervical spine.  The examiner also noted evidence of radiculopathy of the upper extremities, including intermittent pain, paresthesias, and numbness of the upper extremities.
In a May 2017 addendum to the January 2017 examination report, the examiner stated that it was his medical opinion that the claimed lumbar and cervical spine conditions were not proximately caused by, incurred in or otherwise aggravated by active duty.  The examiner did not provide a sufficient rationale for this opinion.
Accordingly, the Board obtained a medical opinion from a neurosurgeon in May 2018.  The neurosurgeon opined that it is unlikely that the current diagnosed low back and cervical spine disabilities are related to military service.  The neurosurgeon noted that the type of injury the Veteran suffered in service is transient, with recovery from the condition standard.  Given the normal separation exam, it appeared that Veteran made full recovery from any lumbar condition.  As to the cervical spine disability, the neurosurgeon indicated no cervical spine or neck injury was noted in service and the normal separation examination indicated no lingering issue at separation.  Moreover, the neurosurgeon also noted that there were multiple references to external injuries the can cause the Veteran’s claimed cervical spine disability.  Finally, it was noted that the diagnosed back or neck strain or pain do not lead to degenerative disc disease, spinal stenosis, or spondylosis.  According to the physician, the Veteran’s currently diagnosed conditions are more likely related to normal aging process than any in-service injury.
Upon review of the evidence, the Board concludes that, while the Veteran has a current diagnosis relating to his neck and back of degenerative arthritis, and evidence shows that in-service complaints of back pain, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis began during service or is otherwise related to an in-service injury, event, or disease.  38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d).
Treatment records show the Veteran was not diagnosed until many years after his separation from service.  While the Veteran is competent to report having experienced symptoms of back and neck pain since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of his current disability.  The issue is medically complex, as it requires knowledge of the interaction between multiple systems in the body and interpretation of complicated diagnostic testing.  Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007).  
Further, the May 2018 VHA opinion indicated that the Veteran’s lumbar and neck disabilities are less likely as not related to an in-service injury, event, or disease, including complaint and diagnosis of back strain.  The rationale was that any in-service condition was transient and resolved by the time of separation, there were multiple intervening injuries after service, and the Veteran’s current disability of degenerative arthritis is more likely related to the normal aging process.  The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).  As such, the Board gives significant probative weight to the May 2018 VHA opinion.  There are no competent opinions to the contrary.  
Consequently, the Board finds that the preponderance of the evidence does not establish a causal nexus between a current lumbar and/or cervical disability and service.  As such, the benefit of the doubt doctrine does not apply, and service connection is not warranted.  See 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App.49, 55 (1990).  
3.  Entitlement to service connection for an acquired psychiatric disorder, claimed as depression, to include as secondary to back disorder
The Veteran contends that he has a psychiatric disorder related to service.  See March 2007 Notice of Disagreement.
Service treatment records do not reflect any treatment for or diagnosis of a psychiatric disorder.  A September 1975 service treatment record noted that mental status was within normal limits, and no psychosis was shown.  
VA medical records reflect a diagnosis of and treatment for major depressive disorder.  See August 2004 VA treatment records. 
The Veteran underwent a VA examination in November 2015.  The examiner noted the Veteran’s extensive medical and social history.  The examiner also noted the Veteran’s current history of treatment for depression.  Upon examination and review of the records, the examiner indicated that the Veteran’s symptoms included depressed mood, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships.  However, the examiner found significant that the Veteran extensively linked depressive symptoms to his physical injuries, including back condition.  Thus, the examiner opined that the Veteran’s depressive disorder is secondary to his back condition.  Further, the examiner noted that the Veteran was never treated in service for mental health issues, but rather was prescribed valium for headaches.  Ultimately, the examiner opined negatively as to any nexus between service and the Veteran’s major depressive disorder. 
Based on the foregoing, the Board finds that service connection for an acquired psychiatric disorder, to include major depressive disorder, is not warranted. 
The competent and probative evidence weighs against a finding of a nexus between military service and the currently diagnosed psychiatric disorder of major depressive disorder.  As noted, service treatment records do not establish a diagnosis of a clinical psychiatric disorder in service, to include depressive disorder.  The November 2015 VA examiner attributed the Veteran’s current psychiatric disorder to factors other than military service, such the Veteran’s back problems for which the Board has denied service connection herein.  Here, the Board finds the clinical opinions provided by the VA medical examiner to be highly probative because he has the appropriate training, expertise and knowledge to evaluate the disorder at issue.  Furthermore, the examiner considered the Veteran’s statements regarding the nature and history of his condition.  The examiner reviewed the pertinent records and provided a thorough rationale for his opinions, which are consistent with the cumulative evidence of record.  The Board also notes that there are no contrary, probative medical opinions.  Additionally, service connection as secondary to a back disorder cannot be granted as the Veteran is not service-connected for the latter.
Although the Veteran contends that his psychiatric disorder is related to service, his lay statements are not competent evidence to establish etiology.  See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007).  His lay statements in this regard clearly fall within the realm of medical expertise.  That is, an opinion regarding the nature and etiology of an acquired psychiatric disorder, to include depressive disorder, is a complex medical question for which lay testimony is not competent evidence.  The Veteran has not demonstrated that he has any specialized medical training which would render him competent to opine on the matter of causal nexus in this case.  As such, the Board finds the Veteran’s opinion regarding the etiology of a psychiatric disorder is not entitled to probative weight. 
As the competent and credible evidence does not demonstrate that a current psychiatric disorder is related to military service, the preponderance of the evidence weighs against the claim.  As such, the benefit of the doubt doctrine does not apply, and service connection is not warranted.  See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990).

Increased Ratings
Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities found in 38 C.F.R. Part 4.  The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations.  38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017).  Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating.  Otherwise the lower rating will be assigned.  38 C.F.R. § 4.7 (2017).   
In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran’s condition.  Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991).  Where, as here, the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a staged rating are required.  See Fenderson v. West, 12 Vet. App. 119, 126 (1999).  The assignment of staged ratings is also appropriate.  See Hart v. Mansfield, 21 Vet. App. 505 (2007). 
4. Entitlement to a compensable initial rating prior to June 14, 2008, and a rating in excess of 30 percent thereafter for headaches 
The Veteran seeks higher ratings for his service-connected headaches.   
Service connection was granted in an October 2006 rating decision and assigned an initial noncompensable rating, effective April 7, 2006.  In September 2009, a 30 percent rating was assigned, effective June 14, 2008.
In April 2006, the Veteran reported sporadic headaches that occasionally required complete bed rest.  The Veteran also reported headaches were incapacitating with inability to function, photophobia, and noise aversion.  See June 2006 correspondence.  The Veteran reported that his last truly bad headache was in 2000 and he has other, non-debilitating headaches.  See March 2007 Notice of Disagreement. 
VA treatment records reflect varying reports as to the frequency, severity, and duration of the Veteran’s headaches.  In December 2004 VA treatment records, the Veteran reported a headache with duration of three weeks, not alleviated by medication and involving gastrointestinal distress, sensitivity to light, and sensitivity to sound.  
At a VA examination in August 2006, the Veteran reported headaches occurring once yearly, lasting one to two months, and associated symptoms of pain, weakness, fatigue, and functional loss.  The Veteran reported taking migraine headache medication.  At a June 2008 VA examination, the Veteran was noted to have a history of headaches occurring twice per month lasting a day and a half.  The examiner noted the headaches were incapacitating when they occurred and were prostrating in that regard. 
In May 2012 VA treatment records, the Veteran noted headaches that restarted in the past year with increased frequency to every three or four days and duration of one to two days.  The Veteran reported associated symptoms of nausea.  In December 2014 VA treatment records, the Veteran was noted to have headaches for the past three days with worsening symptoms, including sensitivity to light, sounds, nausea, and throbbing.  Although the Veteran sought treatment in the Emergency Department, the Veteran left before he could be seen and was not admitted.  On VA examination in November 2015 for psychiatric conditions, the Veteran reported that he had not had a full headache for several years.  In August 2016, the Veteran replied negatively when asked if he had frequent headaches. 
The Veteran underwent an examination in January 2017.  The examiner noted different types of headaches which could not be distinguished.  As to duration, the examiner indicated that headaches lasted less than one day.  The examiner noted that VA treatment records indicated a varying degree of frequency.  Symptoms included pulsating pain and sensitivity to light and sound.  The examiner did not indicate that the Veteran’s headaches were prostrating.  The Veteran was noted to take nonsteroidal anti-inflammatory drugs as needed to treat his headaches.  The examiner concluded that the Veteran could function during a headache, had no admission to hospitals and that his headaches did not cause severe economic hardship.  
A May 2017 VA examination report demonstrates diagnoses of migraine, tension, and sinus headaches.  The Veteran reported symptoms of pulsating and throbbing head pain, pain on both sides of head, and photo and sound sensitivity.  As to duration, the pain typically lasted less than one day.  The Veteran’s treatment plan included medication, noted to be nonsteroidal anti-inflammatory drug.  Neurologic examination showed predominantly normal results.  The examiner’s review of treatment records indicated irregular frequency with headaches occurring every three to four days, once per year, or many years between headaches.  The examiner indicated that there were no prostrating attacks.  Ultimately, the examiner concluded that the condition did not impact the Veteran’s ability to work and that he was able to function while having a headache.  The examiner noted no hospitalizations.  Thus, the examiner indicated that severe economic hardship was absent in this case.  
Upon review of the evidence, the Board finds that higher ratings for headaches are not warranted.  The Veteran’s service-connected headaches are rated under 38 C.F.R. § 4.124a, DC 8100.  Under DC 8100, a 10 percent rating requires headaches with characteristic prostrating attacks occurring on an average of once in 2 months over last several months.  A 30 percent rating is warranted for headaches with characteristic prostrating attacks occurring on an average once a month over the last several months.  A 50 percent rating requires that the disability be manifested by very frequent and prostrating and prolonged attacks that are productive of severe economic inadaptability.
The use of the conjunctive “and” in a statutory provision means that all of the conditions listed in the provision must be met.  See Melson v. Derwinski, 1 Vet. App. 334 (1991).  Here, because of the successive nature of the rating criteria, such that the evaluation for each higher disability rating includes the criteria of each lower disability rating (at least what could be considered most of them), each of the criteria listed in the 50 percent rating must be met in order to warrant such a rating.  See Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009).
The term “productive of severe economic inadaptability” is not defined by VA regulations.  The U.S. Court of Appeals for Veterans Claims (Court), however, has stated that this term is not synonymous with being completely unable to work and that the phrase “productive of” could be read to mean either “producing” or “capable of producing” economic inadaptability.  See Pierce v. Principi, 18 Vet. App. 440, 446-47 (2004). 
For the rating period prior to June 14, 2008, the Veteran is in receipt of a noncompensable rating for headaches.  Upon review, the Board finds the VA examination report and treatment records best reflect the Veteran’s headaches symptoms during this period.  On VA examination in August 2006, the Veteran reported yearly headaches lasting one to two months.  The December 2004 VA treatment records noted a severe headache with duration of three weeks.  To the extent that the headaches reported in these treatment records and examination report are characteristic prostrating attacks, the Board finds the infrequency of the headaches report for most of the year more nearly approximate the criteria for a noncompensable evaluation.  As the preponderance of the evidence does not support a higher rating, the Board finds that a compensable rating prior to June 14, 2008, for headaches is denied.
For the rating period after June 14, 2008, the Veteran is in receipt of a 30 percent rating for headaches.  Here, the Board finds the VA examinations and reports of June 2008, January 2017, and May 2017 are competent and probative evidence on the matter.  The latter two VA examinations note varying frequency of headaches reported; the June 2008 VA examination report noted prostrating headaches occur twice per month.  However, the January and May 2017 VA examination reports noted that the Veteran is able to function during a headache and the headaches do not cause severe economic hardship.  As such, the competent and probative evidence does not reflect very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability.  Therefore, a higher rating for headaches after June 14, 2008, is denied.
The Board acknowledges that in advancing this appeal, the Veteran believes that his disability is more severe than considered by the assigned disability ratings.  However, the Board finds the competent medical evidence offering detailed, specialized determinations pertinent to the rating criteria are the most probative evidence with regards to evaluating the pertinent symptoms for the disability on appeal.  In addition, the medical evidence contemplates the Veteran’s descriptions of his symptoms.  
 
REASONS FOR REMAND
1.  Entitlement to service connection for a disorder manifested by low energy, to include chronic fatigue syndrome, and to include as secondary to type II diabetes mellitus and/or acquired psychiatric disorder
The Veteran seeks service connection for a disability that manifests primarily as low energy.  The Veteran asserts his low energy is secondary to his depression and diabetes.  See March 2007 Notice of Disagreement.  
The record reflects a diagnosis of chronic fatigue syndrome in 1995.  VA treatment records also note fatigue, or low energy, as a chronic symptom of the Veteran’s psychiatric condition.  See e.g. August 2006 VA treatment record.  
A May 2017 VA medical opinion noted the initial diagnosis in 1995.  However, the examiner stated there was no evidence to support the claim that the chronic fatigue syndrome is service-connected.  Upon review, the Board finds the opinion lacks sufficient rationale, and as a result, an addendum opinion is necessary to determine the etiology of any current disorder manifested by low energy, to include chronic fatigue syndrome. 
Further, as this issue is inextricably intertwined with the appeal for type II diabetes mellitus, which is remanded herein, an opinion concerning secondary service connection may be required if service connection for the latter is granted.
2. Entitlement to service connection for type II diabetes mellitus (diabetes), to include as secondary to service-connected disability
The Veteran seeks service connection for diabetes.  The Veteran asserts that an unhealthy diet, improper health care, and lack of education in service contributed to the onset of diabetes.  See June 2006 Correspondence.  The Veteran reports compromised energy levels and elevated blood glucose readings in service.  See March 2007 Notice of Disagreement. 
In a November 2015 VA examination report, the examiner opined that the Veteran’s diabetes is less likely than not to have had onset in service or is otherwise related to service, to include as secondary to service-connected hypertension.  The examiner reasoned that the Veteran underwent GTTs in service with results below the threshold for a diagnosis of diabetes.  Additionally, the examiner explained that patients with glycosuria require blood testing to confirm a diagnosis of diabetes.  The examiner also noted no relationship between the in-service occurrence of renal glycosuria and the subsequent development of diabetes.  Likewise, the examiner eschewed an etiological link between hypertension and diabetes.  Finally, the examiner noted no evidence of manifestation of diabetes during service or within one year of discharge.
Upon review, the Board finds the opinion inadequate for purpose of determining service connection as the examiner did not provide a rationale for the negative opinion concerning a relationship between diabetes and service-connected hypertension, nor did the examiner opine as to whether hypertension aggravated diabetes beyond the natural progression of the disease.  As such, an addendum opinion is warranted.
3. Entitlement to service connection for a heart disorder, to include as secondary to diabetes, hypertension, and/or headaches
The Veteran relates a current heart condition to in-service episodes of dehydration and flu.  See March 2007 Notice of Disagreement.  The Veteran also relates a heart condition to asbestos exposure in army facilities while in service.  See April 2006 VA 21-526.  Alternatively, the Veteran asserts service connection for a heart disorder secondary to hypertension, diabetes, and/or headaches.  
The Veteran is currently in receipt of a diagnosis of heart block or bradycardia.  See November 2015 VA examination.  Service treatment records from December 1974 note a complaint of chest pain with vomiting and body aches. 
The record does not show include a VA examination report and/or medical opinion concerning the etiology of any current heart disorder.  Based on the evidence cited above, the Board finds VA examination and medical opinion are warranted to determine whether any current heart condition is related to the reported asbestos exposure, incident of chest pain in service, or as due to or aggravated by a service-connected disability.   As such, remand is necessary. 
4. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) 
The Board finds that the appeal for entitlement to a TDIU is inextricably intertwined with the claims remanded herein because decisions on the latter may have an impact on the former claim.  Thus, the appeal for entitlement to a TDIU must be remanded for the appropriate development, as well as contemporaneous adjudication.  Harris v. Derwinski, 1 Vet. App. 180 (1991).
The matters are REMANDED for the following actions:
1. Return the record to the clinician who conducted the November 2015 VA examination or an appropriate substitute if unavailable to determine the current etiology of any disorder manifested by low energy, to include chronic fatigue syndrome.  Following a review of the record and any necessary testing, the examiner should address the following inquiries:
(a.) Identify all current disorders manifested by low energy.
(b.) For each disorder, offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such is related to military service.
(c.) If not, offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such disorder is caused or aggravated by a service-connected disability, to include diabetes if service connection for such is granted upon remand.  For any aggravation found, the examiner should state, to the best of his or her ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology.
A rationale should be provided for any opinion proffered.
2. Return the record to the examiner who conducted the November 2015 VA examination or an appropriate substitute clinician if unavailable for an addendum opinion concerning the Veteran’s diabetes.  Following a review of the record, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that diabetes is caused or aggravated by the Veteran’s hypertension.  For any aggravation found, the examiner should state, to the best of his or her ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology.
A rationale for any opinion offered should be provided.  
3. Afford the Veteran an appropriate VA examination to determine the nature and etiology of any current heart disorder.  Following a review of the record and any necessary testing, the examiner should address the following inquiries:
(a.) Identify all current heart disorders.
(b.) For each disorder, offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such is related to his military service, to include an in-service complaint of chest pain and report asbestos exposure.
(c.) If not, offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that a current heart disorder is caused or aggravated by a service-connected disability, to include diabetes if service connection for such is granted upon remand.  For any aggravation found, the examiner should state, to the best of his or her ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology.
A rationale for any opinion offered should be provided.  
 
M. M. CELLI
Acting Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	K. Vuong, Associate Counsel 

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