Citation Nr: 1544206 Decision Date: 10/16/15 Archive Date: 10/21/15 DOCKET NO. 10-04 427A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas THE ISSUES 1. Entitlement to compensation under 38 U.S.C.A. § 1151 for a claimed additional disability of interstitial lung disease, claimed as due to inadequate VA treatment beginning March 1996. 2. Entitlement to service connection for diabetes mellitus Type II, including as due to herbicide exposure. ATTORNEY FOR THE BOARD A. Tenney, Associate Counsel INTRODUCTION The Veteran, who is the appellant, had active service from October 1965 to October 1967. This matter came before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision of the RO in Houston, Texas, which, in pertinent part, denied both service connection for diabetes mellitus and entitlement to compensation under 38 U.S.C.A. § 1151 for a claimed additional disability of interstitial lung disease. The Veteran was previously represented by American Veterans (AMVETS). In a January 2010 letter to the Veteran, prior to issuance of the February 2015 VA Form 8 certifying the appeal to the Board, that organization withdrew its representation. The January 2010 letter advised the Veteran of the option of appointing another representative; the Veteran did not do so. The Veteran had adequate time to obtain new representation; therefore, the Board finds that the Veteran is pursuing this appeal pro se. See 38 C.F.R. § 14.631(c) (2015). The instant matter is a Veterans Benefits Management System (VBMS) appeal. The Board has reviewed both the VBMS and the "Virtual VA" files so as to insure a total review of the evidence. The issue of entitlement to service connection for interstitial lung disease has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Specifically, in a January 2010 Form 9, Appeal to the Board of Veterans' Appeals, the Veteran advanced that the lung disease could be due to herbicide exposure while in service. While the issue of service connection for interstitial lung disease is listed on a February 2015 VA Form 8, Certification of Appeal, and mentioned in the April 2013 supplemental statement of the case (SSOC), the record does not reflect that the RO has addressed this issue. An April 2009 Veteran Claims Assistant Act of 2000 (VCAA) notice, in pertinent part, only lists a claim for "interstitial lung disease caused by the medication methotrexate." In an August 2009 rating decision, the only lung issue adjudicated is the 38 U.S.C.A. § 1151 issue. As such, the Board does not have jurisdiction over the issue of entitlement to service connection for interstitial lung disease, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). FINDINGS OF FACT 1. The currently diagnosed interstitial lung disease was not caused or aggravated by the carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing medical care, including prescribing methotrexate. 2. The interstitial lung disease was not proximately caused by an event not reasonably foreseeable. 3. The Veteran is currently diagnosed with diabetes mellitus Type II. 4. The Veteran did not sustain any injury or disease of the endocrine system in service. 5. The Veteran served in Thailand while on active duty and was not exposed to Agent Orange or herbicides. 6. Symptoms of diabetes mellitus Type II were not continuous since service separation; did not manifest to a compensable degree within one year of service separation; and were initially manifested some 40 years after service. 7. The currently diagnosed diabetes mellitus Type II was not incurred in and is not etiologically related to service. CONCLUSIONS OF LAW 1. The requirements for compensation under 38 U.S.C.A. § 1151 for causation or aggravation of interstitial lung disease, claimed as due to inadequate VA treatment beginning March 1996, have not been met. 38 U.S.C.A. §§ 1151, 5103, 5103A 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.361 (2015). 2. Diabetes mellitus was not incurred in active military service and may not be presumed to have been incurred in active military service, including as due to herbicide exposure. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.326 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and to Assist The VCAA and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.326(a). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In April 2009, a VCAA notice informed the Veteran of the evidence generally needed to support claims for compensation under 38 U.S.C.A. § 1151 and service connection, what actions he needed to undertake, and how VA would assist in developing the claim. The April 2009 VCAA notice was issued to the Veteran prior to the relevant rating decision on appeal. Further, the issues on appeal were readjudicated in a January 2010 Statement of the Case (SOC) and the April 2013 SSOC; therefore, there was no defect with respect to the timing of the VCAA notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). The duty to assist includes providing a veteran an examination and/or obtaining an opinion when it is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The Veteran did not receive a VA examination in conjunction with the claim for service connection for diabetes mellitus. In disability compensation (service connection) claims, VA must provide a medical examination and medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81-82 (2006). The Board finds that the duty to assist in this case does not require obtaining a VA diabetes mellitus examination or opinion. Under the first prong of McLendon, VA must provide a medical examination where there is competent evidence of a current disability. In this case, there is competent medical evidence of a current disability because the Veteran has been diagnosed with diabetes mellitus Type II and VA treatment (medical) records reflect that the Veteran receives treatment for this disability. As to evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period under the second prong of McLendon, there is no evidence to indicate that the Veteran was diagnosed with or had symptoms of diabetes mellitus during service, or for many years after discharge, that the Veteran was exposed to Agent Orange, or sustained an injury to the endocrine system while in service. As the Veteran has made no assertions or submitted any evidence contending onset of symptoms or actual diagnosis of diabetes mellitus Type II in service, the Board finds that VA's duty to assist the Veteran in obtaining additional evidence to support a nexus has not been triggered. See Bardwell v. Shinseki 24 Vet. App. 36, 40 (2010) (holding that, where the evidence has failed to establish an in-service injury, disease, or event, VA is not obligated to provide a medical examination). As such, the Board need not remand to afford the Veteran a VA examination for a medical nexus opinion in support of the issue of service connection for diabetes mellitus. The Board also finds that that the duty to assist does not require obtaining a VA examination or opinion for the 38 U.S.C.A. § 1151 issue. The Veteran has only advanced being uninformed of methotrexate's potential adverse effects; VA treatment records tend to refute the Veteran's contention. Evidence also supports that lung damage is a potential adverse effect of methotrexate, which shows that the lung disability was reasonably foreseeable; therefore, there is sufficient competent medical evidence of record to decide the claim. All relevant documentation, including VA and private treatment records, has been secured and all relevant facts have been developed. There remains no question as to the substantial completeness of the issues of service connection for diabetes mellitus and entitlement to compensation under 38 U.S.C.A. § 1151. 38 U.S.C.A. §§ 5103, 5103A, 5107; 38 C.F.R §§ 3.102, 3.159, 3.326(a). Any duties imposed on VA, including the duties to assist and to provide notification, have been met as set forth above. Compensation Under 38 U.S.C.A. § 1151 Under the provisions of 38 U.S.C.A. § 1151, if VA hospitalization or medical or surgical treatment causes an additional disability which is not the result of the veteran's own willful misconduct or failure to follow instructions, disability compensation may be awarded for a "qualifying additional disability" in the same manner as if the additional disability were service connected. See 38 C.F.R. § 3.361. If an additional disability is present, two principal criteria apply in determining whether it is compensable within the ambit of 38 U.S.C.A. § 1151. First, the additional disability may qualify for compensation if the disability is not the result of the veteran's willful misconduct and the disability was caused by hospital care, medical or surgical treatment, or examination provided under the laws administered by VA. Second, in order to constitute a qualifying additional disability, the proximate cause of the additional disability must have been (1) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the facility furnishing the care, treatment, or examination, or (2) an event not reasonably foreseeable. These provisions of law apply to claims received by VA on or after October 1, 1997. 38 U.S.C.A. § 1151; 38 C.F.R. § 3.361(a). To determine whether an additional disability was caused by medical treatment, VA compares the veteran's condition immediately before the beginning of such treatment to his condition thereafter. To establish causation, the evidence must show that the treatment resulted in the veteran's additional disability. Merely showing that a veteran received care, treatment, or examination and that the veteran has an additional disability does not establish cause. Disability that is due to the continuance or natural progress of the disease is not due to VA treatment unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(b), (c). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing medical treatment proximately caused a veteran's additional disability, it must be shown that the medical treatment caused the additional disability, and that VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or that VA furnished the medical treatment without the veteran's informed consent. Whether the proximate cause of a veteran's additional disability or death was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. 38 C.F.R. § 3.361(d). To determine whether there was informed consent, VA will consider whether the health care provider substantially complied with the requirements of 38 C.F.R. § 17.32 (2015). Minor deviations from the requirements of 38 C.F.R. § 17.32 that are immaterial under the circumstances of a case will not defeat a finding of informed consent. Id. Regulations further provide that compensation is not payable for the necessary consequences of VA treatment properly administered with the express or implied consent of the veteran or, in appropriate cases, the veteran's representative. "Necessary consequences" are those which are certain or intended to result from the treatment provided. Consequences otherwise certain or intended to result from treatment will not be considered uncertain or unintended solely because it had not been determined, at the time consent was given, whether that treatment would, in fact, be administered. 38 C.F.R. § 3.361. In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). After a review of all the lay and medical evidence of record, the Board finds that the weight of the evidence is against a finding that the currently diagnosed interstitial lung disease was caused or aggravated by the carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing medical care, including prescribing methotrexate. The evidence does not reflect the currently diagnosed interstitial lung disease is the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA health care providers who provided treatment. Further, the evidence of record does not reflect that the lung disease was the result of an event that was not reasonably foreseeable. The relevant evidence for this claim consists of the lay statements by the Veteran and Veteran's spouse, and VA and private treatment records. At the outset, the Board notes that the Veteran did not engage in willful misconduct because he was merely taking prescribed medication for rheumatoid arthritis. The contention liberally construed for the Veteran is that the interstitial lung disease was caused by treatment at the Houston VA Medical Center (VAMC), beginning March 2006. VA treatment records reflect that the Veteran was prescribed methotrexate for rheumatoid arthritis in March 2006. In a statement in support of claim received January 2009, the Veteran advanced that the lung disease was caused by VA prescribed methotrexate. In the September 2009 notice of disagreement (NOD) and the January 2010 Form 9, the Veteran asserted only being counseled on methotrexate's potential adverse effects for the liver and not for the lungs. Further, via the January 2010 Form 9, the Veteran also advanced that the lung disease could be due to herbicide exposure while in service. In a written statement received January 2010, the Veteran's spouse contended that the Veteran's lung disease was caused by the VA prescribed methotrexate, or, in the alternative, herbicide exposure while in service. The January 2010 written statement also reflects the Veteran's spouse advanced that the Veteran had developed shortness of breath. Information provided to VA in June 2009 from "SafeMedication" is also associated with the claims file. SafeMedication notes that methotrexate is commonly used to treat rheumatoid arthritis and its adverse effects include liver and lung damage. A March 1996 VA treatment record titled "Medication Counseling," reflects that the Veteran was counseled on the potential adverse effects of methotrexate by a VA pharmacist. The VA treatment record notes that the Veteran acknowledged understanding how to use the methotrexate and what to do if unwanted effects occurred. An October 1996 VA treatment record reflects that the Veteran was prescribed methotrexate in March 1996 to treat an acute flare of rheumatoid arthritis. The October 1996 VA treatment record also notes that the Veteran was again counseled by a VA pharmacist on the potential adverse effects of methotrexate. The October 1996 treatment record indicates that the Veteran was instructed on the dosage change, potential side effects, and medication management due to the dosage increase of the methotrexate. The October 1996 VA treatment record also conveys that the VA pharmacist noted that the Veteran was educated on the safe and effective use of methotrexate and the monitoring of side effects. A private treated record dated June 2008 diagnosed the Veteran's lung disease and conveyed that the biopsy pattern was most consistent with a nonspecific chronic interstitial pneumonitis with mild interstitial fibrosis. The private examiner advanced that the lung disease was likely associated with rheumatoid arthritis, but that methotrexate therapy could have contributed to the "historical process." As such, the private examiner discontinued the Veteran's private methotrexate prescription. The private examiner opined that, because the lung biopsy showed a large number of vacuolated phagocytic cells, the Veteran's lung disease was "more likely related to chronic obstruction as a result of an underlying chronic lung disease secondary to a history of smoking, or a recent episode of acute pneumonia." The June 2008 private treatment record also reflects that an additional private examiner agreed with this opinion. A December 2008 VA treatment record reflects that the Veteran conveyed the recent lung disease diagnosis to the VA examiner upon returning to the Houston VAMC for treatment. After learning of the lung disease diagnosis, the VA examiner discontinued the Veteran's VA methotrexate prescription. Such evidence supports a finding that VA medical professionals knew of, and would have counseled about, the potential lung damage side effects of methotrexate. Upon reviewing all lay and medical evidence of record, the Board finds that the weight of the evidence of record is against a finding that the Veteran has additional disabilities due to VA treatment beginning March 2006. Further, two private examiners opined that the lung disease was likely due to the Veteran's history of smoking, or a recent episode of acute pneumonia. Additionally, the record indicates that both VA and private examiners prescribed methotrexate to the Veteran to treat rheumatoid arthritis. Even if the lung disease was caused by the medication, the Board further finds that the weight of the evidence is against a finding that the March 2006 methotrexate prescription for rheumatoid arthritis was the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA health care providers who provided treatment. The Veteran's contention that he was not advised of all the risk factors prior to taking methotrexate is outweighed by the March 1996 and October 1996 VA treatment records reflecting methotrexate medication counseling by two separate VA pharmacists. SafeMedication also indicates that lung damage is a known adverse effect of methotrexate, and explains that the medication is used to treat rheumatoid arthritis. Further, after the Veteran self-reported the private examiner's June 2008 lung disease diagnosis, in December 2008, the VA examiner discontinued the methotrexate prescription. Further, since both VA and private examiners prescribed methotrexate to treat the Veteran's rheumatoid arthritis, such evidence supports a finding that prescribing the medication was reasonable. The Board finds the March 2006, October 2006, June 2008, and December 2008 VA and private treatment records to be highly probative. The lay statements in this case, to the extent they assert the etiology of the Veteran's lung disease, are found not competent due to the lack of medical expertise. Generally, a veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. Lay assertions may serve to support a claim by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A § 1154 (a) (West 2014); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2006); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). A veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); Jandreau, at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"); see 38 C.F.R. § 3.159(a)(2). The Veteran and Veteran's spouse assert that the Veteran's lung disease was caused by the VA prescribed methotrexate or herbicide exposure while in service. See September 2009 NOD; January 2010 Letter from Spouse. The evidence of record does not indicate that either the Veteran or the Veteran's spouse have the requisite medical knowledge, training, or experience to determine the etiology of lung disease, which is a complex medical question involving intricate anatomical systems. The Board also finds that the lung disease was a reasonably foreseeable risk of the methotrexate because an objectively reasonable health care provider would have considered it to be an ordinary risk of methotrexate. SafeMedication explains that lung damage is a known adverse effect of methotrexate. After the Veteran was diagnosed with lung disease, both VA and private examiners discontinued use of the medication. This suggests that the lung disease was a reasonably foreseeable risk if the methotrexate. Such evidence supports a finding that the VA physician foresaw the risk of lung damage caused by the methotrexate, it was a known risk by a reasonable health care provider, and a reasonable health care provider would have advised the Veteran that the lung disease was foreseeable risk of this medication. For these reasons, the Board finds that a preponderance of the evidence is against a finding that the Veteran has an additional lung disability that was proximately caused by VA treatment beginning in March 2006; that the interstitial lung disease was proximately caused by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, including prescribing methotrexate; or that the interstitial lung disease was an event that was not reasonably foreseeable; therefore, compensation under 38 U.S.C.A. § 1151 is not warranted. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim must be denied. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Service Connection for Diabetes Mellitus Service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). In this case, the Veteran has been diagnosed with diabetes mellitus Type II, which is listed as a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions based on "chronic" in-service symptoms and "continuous" post-service symptoms under 38 C.F.R. § 3.303(b) apply to the claim. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Under 38 C.F.R. § 3.303(b), service connection will be presumed where there are either chronic symptoms shown in service or continuity of symptomatology since service for diseases identified as "chronic" in 38 C.F.R. § 3.309(a). Walker, 708 F.3d at 1338-40 (holding that continuity of symptomatology is an evidentiary tool to aid in the evaluation of whether a chronic disease existed in service or an applicable presumptive period). With a chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). In addition, the law provides that, where a veteran served ninety days or more of active service, and certain chronic diseases, such as diabetes mellitus, manifest to a degree of ten percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A §§ 1101, 1112, 1113, 1137 (West 2014); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Service connection may also be granted on a presumptive basis for certain diseases associated with exposure to certain herbicide agents, even though there is no record of such disease during service, if they manifest to a compensable degree any time after service, in a veteran who had active military, naval, or air service for at least 90 days, during the period beginning on January 9, 1962 and ending on May 7, 1975, in the Republic of Vietnam, including the waters offshore, and other locations if the conditions of service involved duty or visitation in Vietnam. 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307, 3.309(e), 3.313. This presumption may be rebutted by affirmative evidence to the contrary. 38 U.S.C.A. § 1113; 38 C.F.R. §§ 3.307, 3.309. The following diseases are deemed associated with herbicide exposure under VA law: AL amyloidosis, Chloracne or other acneform disease consistent with chloracne, Type II diabetes (also known as diabetes mellitus Type II or adult-onset diabetes), Hodgkin's disease, Ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), Multiple myeloma, Non-Hodgkin's lymphoma, Parkinson's disease, early onset peripheral neuropathy, Porphyria cutanea tarda, Prostate cancer, Respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and Soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). As such, diabetes mellitus is a disability for which presumptive service connection based exposure to herbicides may be granted. Id. Notwithstanding the foregoing presumption provisions for herbicide exposure, a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); see also Ramey v. Gober, 120 F.3d 1239, 1247-48 (Fed. Cir. 1997), aff'g Ramey v. Brown, 9 Vet. App. 40 (1996); Brock v. Brown, 10 Vet. App. 155, 160-61 (1997). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran contends that the diabetes mellitus is related to herbicide exposure while on active duty in Thailand. Service personnel records indicate that the Veteran served in Thailand from March 1966 to April 1967. Further, VA and private treatment records reflect that the Veteran has a current diagnosis of diabetes mellitus. After a review of all the lay and medical evidence of record, the Board finds that the weight of the evidence is against a finding that the currently diagnosed diabetes mellitus had its onset in service or is otherwise causally or etiologically related to service. The Veteran did not sustain any injury or disease of the endocrine system in service, and symptoms of diabetes mellitus Type II were not continuous since service separation; did not manifest to a compensable degree within one year of service separation; and were initially manifested some 40 years after service. The Board further finds that the Veteran was not exposed to Agent Orange during active duty. Additionally, the Veteran's endocrine system was clinically evaluated as normal at the August 1967 service separation examination, and on the August 1967 Report of Medical History, the Veteran checked "no" when asked if he currently, or at any time ever had high or low blood pressure. As to whether the Veteran was exposed to herbicide agents during service, service personnel records do not reflect that the Veteran served in the Republic of Vietnam during the Vietnam War. The Veteran's service personnel records document service in Thailand during the Vietnam War. Specifically, the service personnel records indicate active service in Thailand from March 1966 to April 1967. The majority of troops in Thailand during the Vietnam Era were stationed at the Royal Thai Air Force Bases of U-Tapao, Ubon, Nakhon Phanom, Udorn, Takhli, Korat, and Don Muang. If a veteran served on one of these air bases as a security policeman, security patrol dog handler, member of a security police squadron, or otherwise served near the air base perimeter, as shown by MOS (military occupational specialty), performance evaluations, or other credible evidence, the herbicide exposure should be acknowledged on a facts-found or direct basis. This applies only during the Vietnam Era, from February 28, 1961 to May 7, 1975. See M21-1MR, Part IV, Subpart ii, Chapter 2, Section C.10.(q). Service personal records show that the Veteran served in the 809th Engineer Battalion as a Machine Operator. Further, a VA memorandum associated with the file titled "Herbicide use in Thailand during the Vietnam Era," reported that Agent Orange was only tested in Thailand for six days in September 1964; the Veteran was deployed to Thailand in March 1966. As such, exposure to herbicide agents is not presumed under 38 U.S.C.A. § 1116 and 38 C.F.R. §§ 3.307, 3.309(e), 3.313. Similarly, the Board finds that the weight of the evidence is against a finding that symptoms of diabetes mellitus were "chronic" in service. The Board notes that the service treatment records appear complete, and that diabetes is a condition that would have ordinarily been recorded during service; therefore the complete service treatment records, which were generated contemporaneous to service, are likely to accurately reflect the Veteran's physical condition, are of significant probative value. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (citing Fed. R. Evid. 803(7) for the proposition that the absence of an entry in a record may be evidence against the existence of a fact if it would ordinarily be recorded); AZ v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013) (recognizing and applying the rule that the absence of a notation in a record may be considered if it is first shown both that the record is complete and also that the fact would have been recorded had it occurred). Service treatment records do not include any complaints, treatment, or symptoms of an injury or disorder related to the endocrine system. As discussed above, the Veteran's endocrine system was clinically evaluated as normal at the August 1967 service separation examination, and the Veteran has not asserted any symptoms of diabetes in service. As such, the Board finds that symptoms of diabetes mellitus were not chronic in service. The Board next finds that the weight of the evidence demonstrates that symptoms of diabetes mellitus have not been continuous since service separation in October 1967. As noted above, the Veteran did not report any blood pressure trouble or other diabetes mellitus symptoms in the August 1967 Report of Medical History. A post-service VA treatment note from November 2006 reflects that the Veteran had not yet been diagnosed with diabetes mellitus. A subsequent private treatment record from June 2008 denotes a diabetes mellitus diagnosis, indicating that the Veteran was not diagnosed with diabetes until some 40 years after service separation. The Veteran has also not asserted that diabetes symptoms first manifested after service separation in August 1967. For these reasons, the Board finds that the symptoms of diabetes mellitus were not continuous after service separation. The Board also finds that the evidence does not show that the Veteran's diabetes mellitus manifested to a compensable degree (i.e., at least 10 percent) within one year of service separation. As previously discussed, the evidence of record demonstrates that the onset of diabetes was approximately 40 years after service separation. As such, presumptive service connection under 38 C.F.R. § 3.309(a) does not apply. Regarding the theory of direct service connection, the Board finds that the diabetes mellitus is not related to an in-service injury or disease because the weight of the evidence demonstrates no in-service injury or disease or even event to which diabetes could be related. As discussed above, while the Veteran contends that his diabetes mellitus is related to exposure to Agent Orange in Thailand, Agent Orange is presumed to have occurred during the period beginning on January 9, 1962 and ending on May 7, 1975, in the Republic of Vietnam and not Thailand. Service treatment records reflect no injury or disease to the endocrine system. For these reasons, the Veteran's currently diagnosed diabetes mellitus, which did not manifest until approximately 40 years after service, is not attributable to service. While the Veteran is competent to relate symptoms of diabetes mellitus experienced at any time, he is not competent to opine on whether there is a link between the current diabetes and active service, including to the alleged exposure to herbicides, because such a conclusion regarding causation requires specific, highly specialized, medical knowledge and training regarding the unseen and complex processes of the endocrine system, knowledge of the various risk factors and causes of diabetes, specific clinical testing for diabetes that indicate onset, and knowledge of the incubation period or ranges of such disorders that the Veteran is not shown to possess. See Rucker, 10 Vet. App at 74 (stating that a lay person is not competent to diagnose or make a competent nexus opinion about a disorder as complex as cancer). For these reasons, the Board finds that the preponderance of the lay and medical evidence that is of record weighs against the claim of service connection for diabetes mellitus Type II; consequently, the claim must be denied. The preponderance of the evidence is against all the theories of the claim; therefore the benefit of the doubt doctrine does not apply. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Compensation under 38 U.S.C.A. § 1151 for interstitial lung disease, claimed as due to VA treatment beginning March 1996, is denied. Service connection for diabetes mellitus Type II, including as due to herbicide exposure, is denied. ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs