Citation Nr: 0615230 Decision Date: 05/24/06 Archive Date: 06/02/06 DOCKET NO. 97-22 740 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in No. Little Rock, Arkansas THE ISSUE Entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for diabetes mellitus with peripheral neuropathy. REPRESENTATION Appellant represented by: Mark R. Lippman, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. L. Wright, Counsel INTRODUCTION The veteran had active service from November 1952 to May 1955. This matter came before the Board of Veterans' Appeals (Board) on appeal from a June 1995 rating decision of the Department of Veterans Affairs (VA) North Little Rock, Arkansas, Regional Office (RO) which denied compensation under the provisions of 38 U.S.C.A. § 1151 (West 1991) for diabetes mellitus with peripheral neuropathy. The Board issued an initial decision regarding this matter in May 1999, which denied the veteran's claim. He subsequently appealed this determination to the United States Court of Appeals for Veterans Claims (Court), which vacated the Board's decision and remanded for further development. In turn, the Board remanded this case to the Agency of Original Jurisdiction in March 2000, February 2004, and March 2005 for development of the evidence and to insure the veteran received appropriate notification of his procedural/appellate rights. The case has now returned for appellate consideration. FINDINGS OF FACT 1. The veteran is service connected for post-operative duodenal ulcer with hyperacidity due to incomplete vagotomy, effective from May 11, 1955. 2. The veteran underwent a vagotomy, a gastrojejunostomy, an appendectomy, and an umbilectomy in March 1958 at the Memphis, Tennessee, VA Medical Center for treatment of a duodenal ulcer. He subsequently underwent an additional vagotomy and surgical repair of a hiatal hernia in May 1963 at the same facility. 3. The veteran was first diagnosed with adult onset non insulin dependent diabetes mellitus (Type II) in 1989. 4. The evidence establishes that the veteran's diabetes mellitus and associated diabetic peripheral neuropathy are not related to his March 1958 and May 1963 gastrointestinal surgical procedures. CONCLUSION OF LAW Diabetes mellitus with peripheral neuropathy was not incurred as the result of VA surgical treatment. 38 U.S.C.A. §§ 1151, 5107 (West 1991); 38 C.F.R. § 3.358 (effective prior to October 1, 1997). See 63 Fed. Reg. 45004 (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSION VCAA The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) introduced several fundamental changes into the VA adjudication process. It eliminated the requirement under the old 38 U.S.C.A. § 5107(a) (West 1991) that a claimant must present a well- grounded claim before the duty to assist is invoked. A VCAA notice letter consistent with 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; (3) inform the claimant about the information and evidence the claimant is expected to provide; and (4) request or tell the claimant to provide any evidence in the claimant 's possession that pertains to the claim. VA satisfied this duty by means of letters to the appellant issued in March 2004, March 2005, April 2005, June 2005, and March 2006. These letters informed him of the requirements to establish entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for diabetes mellitus with peripheral neuropathy. He was advised of his and VA's respective duties and asked to submit information and/or evidence pertaining to the claim to VA. The Board notes that the appropriate VCAA notification was not issued prior to the initial adverse decisions of 1995. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, this deficiency was corrected by the Board remand of February 2004, the issuance of the above noted letters, and the AOJ's subsequent readjudication of the issue in the SSOCs issued in September 2004 and January 2006. See 38 C.F.R. § 1931(c) (The AOJ will issue a SSOC, pursuant to a remand by the Board, to cure a procedural defect.) In the present appeal, the veteran was provided with notice of what type of information and evidence was needed to substantiate his claim for compensation under the provisions of 38 U.S.C.A. § 1151, but he was not provided with notice of the type of evidence necessary to establish a disability rating or effective date for the disability on appeal. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Despite the inadequate notice provided to the veteran on these latter two elements, the Board finds no prejudice to the veteran in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (Where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the veteran has been prejudiced thereby.) In that regard, as the Board concludes below that the preponderance of the evidence is against the appellant's claim for compensation under the provisions of 38 U.S.C.A. § 1151, any questions as to the appropriate disability rating or effective date to be assigned are rendered moot. VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claims for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a); 38 C.F.R. § 3.159(c), (d). By the VCAA letters discussed above, VA requested that the veteran identify evidence pertinent to this claim. The veteran has identified both private and VA treatment. These identified records have been obtained and associated with the claims file, to include VA treatment records from the Alexandria, Louisiana VA Medical Center (VAMC) and Baton Rouge, Louisiana VA Outpatient Clinic dated in 1989, as mandated by the Court's and Board's remands. The veteran and his attorney have informed VA as late as July 2005 that there is no additional evidence and requested that the Board adjudicate this claim on its merits. Therefore, the Board finds that there are no other pertinent medical/treatment records identified by the veteran or records that require further development. Assistance shall also include providing a medical examination or obtaining a medical opinion when such an examination or opinion 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 was provided a VA compensation examination in connection with the current claim on appeal in August 1993. In addition, VA medical opinions were obtained in January 1999 and October 2002 that discussed the etiology of the veteran's claimed conditions. The veteran has also submitted private medical opinions that discuss the etiology of his diabetes mellitus and these opinions are considered by the Board in the following decision. Based on this analysis, the Board finds that the VA examination reports and opinions are adequate for VA purposes. The veteran was given an opportunity to request a hearing before the Board on the Substantive Appeal (VA Form 9) he submitted in September 1996. He declined this opportunity. However, he did request a hearing at the RO before a local Hearing Officer. This hearing was conducted in January 1996 and a transcript of this hearing has been associated with the claims file. Based on the above analysis, the Board concludes that further development is not required and adjudication of this claim is appropriate at this time. Based on the Court's direction, the Board has remanded this case for development in March 2000, February 2004, and March 2005. In March 2000, the AOJ was instructed to obtain VA treatment records dated in 1989 from the Alexandria VAMC. These records, to include outpatient records from the Baton Rouge Outpatient Clinic dated in 1989, were received September 2000 and May 2001. In February 2004, the AOJ was instructed to issue the appropriate VCAA notification letters and inform the veteran of his responsibility to submit medical evidence to substantiate his claim. Such a notification was initially issued in March 2004 and subsequent notification letters discussed above. In March 2005, the AOJ was instructed to request treatment records from an identified private physician. This request was issued in June 2005. In July 2005, the veteran's attorney informed VA that all treatment records from this physician had previously been submitted and no additional records exist. Based on this development and analysis, the Board finds that the AOJ has fully complied with the remand instructions of the Court and Board and further remand to enforce these instructions is not warranted. See Stegall v. West, 11 Vet. App. 268 (1998). To the extent that VA in any way has failed to fulfill any duty to notify and assist the appellant, the Board finds that error to be harmless. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2001) (The "harmless error doctrine" is applicable when evaluating VA's compliance with the VCAA). Of course, an error is not harmless when it "reasonably affected the outcome of the case." ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). As all pertinent evidence obtainable by VA has been associated with the claims file, the Board finds that the duty to assist has been fulfilled and any error in the duty to notify would in no way change the outcome of the below decision. The notification provided to the appellant in the letters, SOCs, SSOCs, and Board remands discussed above provided sufficient information for a reasonable person to understand what information and evidence was needed to substantiate the claim on appeal. In addition, the Board notes that the appellant has continuously received expert representation by a licensed attorney since the Court's remand in 1999. In this regard, while perfection is an aspiration, the failure to achieve it in the administrative process, as elsewhere in life, does not, absent injury, require a repeat performance. Miles v. M/V Mississippi Queen, 753 F.2d 1349, 1352 (5th Cir. 1985). Based on the above analysis, the Board determines that no reasonable possibility exists that further assistance would aid in the substantiation of the appellant's claim. 38 U.S.C.A. 5103A. In addition, as the appellant has been provided with the opportunity to present evidence and arguments on his behalf and availed himself of those opportunities, appellate review is appropriate at this time. See Bernard, supra. Compensation under 38 U.S.C.A. § 1151 The veteran asserts on appeal that he underwent gastrointestinal surgery at the Memphis, Tennessee, VA Medical Center in 1958 and 1963 and subsequently developed diabetes mellitus and peripheral neuropathy as a consequence of the procedures. He contends that compensation under the provisions of 38 U.S.C.A. § 1151 (West 1991) for those disabilities is now warranted. The Board initially observes that 38 U.S.C.A. § 1151 has been amended during the pendency of the instant appeal. The effective date of the amended statute is October 1, 1996. In a precedent opinion dated December 31, 1997, the Acting General Counsel of the VA concluded that "all claims for benefits under 38 U.S.C. § 1151, which governs benefits for persons disabled by treatment or vocational rehabilitation, filed before October 1, 1997, must be adjudicated under the provisions of section 1151 as they existed prior to that date." VAOPGPREC 40-97 (Dec. 31, 1997). As the veteran's claim for compensation under 38 U.S.C.A. § 1151 was filed in January 1993, the claim will be considered under 38 U.S.C.A. § 1151 (West 1991). The statute provides, in pertinent part, that where any veteran shall have suffered an injury, or an aggravation of an injury, as the result of hospitalization, medical or surgical treatment, not the result of such veteran's own willful misconduct, and such injury or aggravation results in additional disability to or the death of such veteran, disability or death compensation under this chapter and dependency and indemnity compensation under chapter 13 of this title shall be awarded in the same manner as if such disability, aggravation, or death were service-connected. A May 1958 VA hospital summary indicates that the veteran was hospitalized at the Memphis, Tennessee, VAMC for treatment of his chronic duodenal ulcer and subsequently underwent a vagotomy, a gastrojejunostomy, an appendectomy, and an umbilectomy in March 1958. A June 1963 VA hospital summary conveys that the veteran was again hospitalized at the Memphis, Tennessee, VAMC and subsequently underwent an additional vagotomy and surgical repair of a hiatal hernia in May 1963. VA outpatient record dated in June 1989 from the Baton Rouge VA Outpatient Clinic noted the veteran's complaints of tingling in both lower extremities for the past month. He reported that he had been given a questionable diagnosis for diabetes several years before. The diagnosis was to rule out peripheral neuropathy. The following day, his fasting blood sugar level was reported to be 237. He was referred to the VA nutrition clinic with a provisional diagnosis of diabetes mellitus. Follow-up examination in August 1989 noted that the veteran appeared to be following his diet. His blood sugar glucose level was reported to be 111 and was noted to have improved on the diet. An April 1990 VA treatment record notes that the veteran complained of bilateral foot numbness and burning since May 1989. The impression was peripheral neuritis of the feet. A May 1990 VA treatment record reflects that the veteran again complained of numbness of the feet. The noted impression was neuropathy. A December 1990 VA treatment record states that the veteran complained of a progressive "prickly" sensation in the left arm, the fingers, and the feet of one month's duration. The veteran reported that he had been told that he had diabetes mellitus in 1972. An impression of peripheral neuropathy was advanced. In his January 1991 claim for increased disability compensation, the veteran claimed that he experienced hyperglycemia, night sweats, nausea, and numbness of the left side of his jaw, the right hand, the lower legs, and the feet. VA clinical documentation dated in January 1991 states that the veteran complained of numbness of the feet. He was diagnosed with non-insulin dependent diabetes mellitus and peripheral neuropathy. A February 1991 VA neurological evaluation notes the veteran's history of diabetes mellitus of one month's duration; alcohol use; and prior gastrointestinal surgeries. An impression of peripheral neuropathy was noted. The VA physician commented that the peripheral neuropathy was "most likely [secondary] to combination of factors ([alcohol] + [diabetes mellitus] + [questionable history] of gastro[intestinal] surgery) [] causing nutritional deficiency." In an undated written statement received in April 1991, the veteran related that a VA physician at the Nashville, Tennessee, VAMC had told him that his 1958 and 1963 surgical procedures caused his diabetes mellitus which, in turn, caused the damage to the nerve endings. At an October 1991 VA examination for compensation purposes, the veteran complained of pain in the balls of his feet of one year's duration. The veteran was diagnosed with a duodenal ulcer post operative hyperacidity-incomplete vagotomy; post- gastrectomy syndrome; possible diabetes mellitus; and possible peripheral neuropathy. The VA examiner commented that, "[i]n my opinion[,] diabetes [mellitus] and peripheral neuropathy[,] if found[,] are not secondary conditions caused by his service[-]connected ulcer." A VA neurology consultation conducted in January 1992 noted an assessment for peripheral neuropathy. The examiner attributed this condition to the veteran's diabetes and alcohol consumption. An October 1992 VA hospital summary conveys that the veteran had a history of diabetes mellitus of three years' duration and peripheral diabetic neuropathy. In his January 1993 claim for compensation under the provisions of 38 U.S.C.A. § 1151 (West 1991), the veteran advanced that the 1958 and 1963 surgical procedures performed at the Memphis, Tennessee, VAMC caused both diabetes mellitus and damage to his hands and feet. He stated that treating VA physicians at the Alexandria, Louisiana, VAMC had informed him in 1989 that his gastrointestinal surgeries caused both diabetes mellitus and a "foot and hand condition." At an April 1993 VA examination for compensation purposes, the veteran was reported to have a history of diabetes mellitus "for the last three years." The veteran was diagnosed with a "history of diabetes mellitus." In a June 1993 written statement, the veteran reiterated that his diabetes mellitus and peripheral neuropathy were caused by his 1958 and 1963 gastrointestinal surgical procedures. An August 1993 written statement from O.H.C., Jr., M.D. (internal medicine), indicates that the veteran presented a history of a subtotal gastrectomy and the subsequent development of diabetes mellitus. Dr. O.H.C. stated that: In my opinion, his diabetes mellitus could have possibly been precipitated by his subtotal gastrectomy but certainly the subtotal gastrectomy makes absorption and utilization of glucose somewhat more difficult. At an August 1993 VA examination for compensation purposes, the veteran was diagnosed with post-operative vagotomy, pyloroplasty, and hiatal hernia repair residuals and non- insulin dependent diabetes mellitus with peripheral neuropathy. The VA examiner concluded that: [T]his man's diabetes is in no way related to his [s]ervice[-c]onnected stomach problem. He had a hiatal hernia repair and peptic ulcer surgery, but these in no way predisposed (sic) people to developing diabetes. The etiology of his diabetes would be the same etiology that you would expect in an adult patient. This is a relative deficiency of insulin production due to failure of the islet cells of the pancreas. A November 1995 written statement from A.R.F., M.D., conveys that: Writing in reference to [the veteran] with significant past medical history of vagotomy and pyloroplasty for hiatal hernia repair and ulcer[-]related difficulties. The patient subsequently has become a non-insulin dependent diabetic since then. It is well documented that these patients may be venerable (sic) to deficiencies in the production and absorption of insulin, and subsequently becoming non-insulin dependent diabetes (sic). Of course, this is not the only viable explanation for this gentleman's diabetes, but should be strongly considered as a contributor to his overall disease. At the January 1996 hearing on appeal, the veteran testified that he began to have "problems with sugar in my urine" in 1972. He was subsequently told by VA physicians at the Memphis, Tennessee, VAMC in 1972 that the condition was caused by his prior gastrointestinal operations. The doctors had clarified to him that he was not a diabetic. He was initially diagnosed with diabetes mellitus in 1989 and subsequently developed peripheral neuropathy. In an undated written statement, the veteran clarified that he had been actually informed of the etiological relationship between his gastrointestinal surgeries and the onset of diabetes mellitus by a VA physician in 1968 or 1969 rather than 1972. The January 1999 Veterans Health Administration (VHA) opinion thoroughly notes the veteran's medical history. The VA physician commented that: This veteran had two surgical procedures to treat the duodenal ulcer disease as well as repair a hiatal hernia. He developed diabetes mellitus more than two decades later. Partial gastrectomy, [B]illroth II anastomosis, vagotomy, and hiatal hernia repair are in no way related to the onset of diabetes mellitus in any patient. The peripheral neuropathy is a result of the diabetes itself causing nerve damage. This patient has diabetes for the same reason as any other adult patient may develop diabetes mellitus (a result of decreased production of insulin in the islet cells of the pancreas or a relative insensitivity of the insulin receptors to the circulating insulin). A private physician (R.T., M.D.) that specialized in internal medicine prepared an opinion in October 2000. This physician indicated a history that was based on the recitation of the veteran. It was noted that the veteran had developed "dumping syndrome" and a B-12 vitamin deficiency after his 1958 gastrointestinal surgery that removed a large amount of stomach. This physician also noted that the veteran had stomach surgery in 1963. Dr. R.T. commented: In my personal opinion, the above mentioned stomach surgery could cause the [veteran] to have a decrease in parietal cells, which could cause the [veteran] to have a vitamin deficiency. A private physician, C.N.B., M.D. (self-described as a "neuro-radiologist") prepared an opinion in March 2002. He noted that his opinion was based on a review of the medical history contained in the claims file. Based on this review, he opined that the veteran's peripheral neuropathy was the result of diabetes mellitus, and that the veteran's diabetes mellitus is the result of his service-connected ulcer disease and subsequent gastric surgeries which had caused dumping syndrome. Dr. C.N.B.'s reasons and bases for this opinion included a history of the veteran entering active service with a normal enlistment physical, that he existed service status post gastric ulcer disease, that he experienced chronic gastric ulcer problems since his active service, the veteran developed "dumping syndrome" post VA gastric surgery, that the medical literature supported an association between the veteran's types of gastric surgery and dumping syndrome, and that his opinion is consistent with opinions provided by the veteran's private treating physicians. In support of this opinion, the Dr. C.N.B. noted excerpts from two medical articles/tests that reported patients after receiving certain gastric surgeries evidence dumping syndrome on the basis of increased levels of plasma volume and blood glucose. Another article indicated that the increment of insulin, enteroglucagon, and neurotensin was greater in the postoperative patients with dumping symptoms than in the postoperative and preoperative patients without dumping syndrome. Dr. C.N.B. noted VA medical opinions that had opined that the etiology of the veteran's diabetes mellitus was not due to his VA surgery. He disagreed with these opinions on the bases that these physicians did not consider the effects of dumping syndrome has no glucose metabolism and its relationship to diabetes, and that the VA physicians likely did not review the entire medical record because none of them addressed or evaluated the other positive or negative opinions of record. Finally, Dr. C.N.B. noted the medical definitions/causes of diabetes. These included Type I (insulin dependent diabetes - IDDM), Type II (adult onset, non insulin dependent diabetes - NIDDM), genetic defect/syndromes, disease of the exocrine pancreas, endocrinopathies, drug or chemical induced, infections, uncommon forms of immune mediated diabetes, and gestational diabetes. He then commented: This patient is not your average patient and therefore the above list does not necessary apply. [The VA physicians] should not consider or classify this patient as average but rather they should take into account his 30-year history of dumping syndrome and give him an alternative etiology of his diabetes. Neither physician gave this patient a specific alternative etiology for his diabetes they simply stated that this patient would be like the average patient and would be expected to have the average type of diabetes. This patient has a negative family history for diabetes. The patient likely has an diabetes based on abnormal glucose utilization which has caused long standing abnormal endocrine levels (insulin, enteroglucagon, neurotensin) therefore, this patient would likely fall into the endocrinopathy like category (of diabetes)...It is my opinion that without a specific alternative medically sound etiology, from [the VA physicians], for this patient 's diabetes, dumping syndrome secondary to gastric surgery for service related ulcer disease is the most likely cause. In March 2002, the veteran submitted a medical article that noted research revealed deficiency in vitamin B-12 may cause a symmetrical neuropathy, affecting the lower limbs more than the upper, and involving the posterior and lateral columns of the spinal cord. A medical opinion was prepared by a VA gastrointestinal physician/specialist and a register nurse in October 2002. The physician indicated that he had reviewed the medical history in the claims file. He indicated his agreement with Dr. C.N.B. that the veteran's gastric surgery could cause dumping syndrome and would require him to eat six meals a day. However, he disagreed with Dr. C.N.B.'s conclusion that this dumping syndrome had resulted in diabetes mellitus. He noted the VA physician's opinion of January 1999 and indicated that he concurred with this physician's conclusions and reasons and bases. The VA gastroenterologist also noted that this opinion was supported by the fact that the veteran was diagnosed with non-insulin dependent diabetes over 30 years after his gastric surgery. A private physician, A.A.C., M.D. (internal medicine), prepared a letter to VA in March 2004. Dr. A.A.C. noted that the veteran underwent gastric surgery "many years ago," and subsequently had distinct symptoms of "dumping syndrome" and episodes of hypoglycemia. It was Dr. A.A.C.'s opinion that the veteran's symptoms are related to his pervious surgery. In a statement signed in March 2004, the veteran's ex-spouse attested that they had visited a VA physician at the Memphis, Tennessee VAMC in 1968 or 1969 after the veteran had completed a fasting blood sugar test. He was reportedly informed at that time he was diabetic and that this condition had been caused by his gastric surgery had caused his elevated sugar levels. The Board has reviewed the probative evidence of record including the veteran's testimony and statements on appeal. The record reflects that the veteran underwent a vagotomy, a gastrojejunostomy, an appendectomy, and an umbilectomy at the Memphis, Tennessee, VAMC in March 1958 and an additional vagotomy and surgical repair of a hiatal hernia at the same facility in May 1963. He developed non-insulin dependent diabetes mellitus (Type II) in approximately 1989 or 1990 and subsequently developed diabetic peripheral neuropathy. The veteran has testified on appeal that he was informed by a VA doctor in 1968 or 1969 that his gastrointestinal surgical procedures had caused the presence of sugar in his urine. He denied having been told that he had diabetes mellitus at that time. The record is devoid of any objective documentation reflecting such a discussion. The doctor is not identified and even the year of the discussion has changed from 1972 to 1968 or 1969. While the veteran and his spouse have attested to this event, the Board finds that these statements are not reliable and have little probative value. The veteran's and his spouse's statements as to what they may have been told by a doctor is unsupported and does not constitute competent evidence. See Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992) (Statement of appellant as to what a physician told him is insufficient to establish a diagnosis); see also Madden v. Gober, 125 F.3d 1477, 1480-81 (Fed. Cir. 1997) (An appellant's claims can be contradicted by the contemporaneous evidence); Washington v. Nicholson, 19 Vet. App. 362, 366-67 (2005) (The Board is required to assess the credibility of lay evidence.) We also note that there is no indication that this particular statement was ever in written form, the doctor has not been identified, and a reasonably accurate date has not been established. There is no duty to attempt to obtain a document that does not exist or cannot be located. See Warren v. Brown, 6 Vet .App. 4, 6 (1993). Furthermore, there is no indication that the claimed conversation was reduced to written form and the appellant has indicated that there is no outstanding evidence. When all the evidence is assembled, the Secretary, is then 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 the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board is required to analyze, weight, and reconcile the evidence before it, to include conflicting medical evidence. See Cousino v. Derwinski, 1 Vet. App. 536 (1991); Cohen v. Brown, 10 Vet. App. 128, 153 (1997). The veteran, as a lay person, is competent to present evidence regarding injuries and symptomatology. However, he is usually not competent to present evidence regarding diagnoses and etiology of a disease, such as diabetes, that is not ascertainable by direct lay observation. See Espiritu, supra. The record does contain conflicting medical opinions as to the etiology of the veteran's diabetes mellitus and associated diabetic peripheral neuropathy. The favorable evidence includes, Dr. O.H.C. advanced that the veteran's "diabetes mellitus could have possibly been precipitated by his subtotal gastrectomy." Dr. A.R.F. indicated that it was "well documented" that individuals who underwent gastrointestinal surgeries similar to the veteran's 1958 and 1963 procedures may be vulnerable "to deficiencies in the production and absorption of insulin and subsequently become non-insulin dependent diabetics." Dr. A.R.F. noted that the veteran's surgical procedures were "not the only viable explanation" for the onset of diabetes mellitus. The February 1991 VA neurological evaluation attributed the veteran's peripheral neuropathy to a combination of factors without establishing a clear relationship to the operative procedures. Dr. A.A.C. opined that the veteran's dumping syndrome and episodes of hypoglycemia were related to "previous surgery." Finally, Dr. C.N.B. provided a long and detailed opinion finding the VA gastric surgeries had resulted in a dumping syndrome that eventually led to a type of endocrinopathic diabetes mellitus. Reviewing these opinions, the Board notes that it does not appear that Dr. O.H.C., A.R.F., or the VA examiner of February 1991 had access to the veteran's entire medical history contained in the claims file in rendering there opinions. See Godfrey v. Brown, 8 Vet. App. 113, 121 (1995) (VA is not required to accept a physician's opinion that is based upon a claimant's recitation of an uncorroborated medical history.) Other than noting the veteran's past VA gastric surgery, there was no substantial medical history noted in these opinions. Furthermore, the opinions are lacking in detail or support of the conclusions. In addition, Dr. O.H.C.'s opinion is too equivocal to be considered probative of the etiology of the veteran's diabetes. That is, the nexus was expressed in the non- definitive term "could have possibly been" precipitated by the gastric surgery. This type of evidence does not establish that it was at least as likely as not that the gastric surgery precipitated the subsequent diabetes mellitus. It is noted that Dr. A.R.F. appears to provide a more definitive nexus between the gastric surgery and the subsequent diabetes. However, while Drs. O.H.C. and A.R.F. advanced that there was a possibility that the veteran's diabetes mellitus was etiologically related to his gastrointestinal surgical procedures, they did not conclude that such a relationship actually existed. Indeed, Dr. A.R.F. stated only that patients with surgical histories similar to the veteran's history were more vulnerable to diabetes mellitus and readily acknowledged that there were other "viable explanations" for the onset of the disability. Thus, Drs. O.H.C. and A.R.F.'s statements merely raise a possibility of a relationship. While Dr. A.R.F. claimed that the medical literature supported this conclusion, he failed to provide a detailed reasons for this nexus or cite to any authoritative medical treatise that in fact supported this position. In addition, this opinion appears inconsistent with the favorable opinion of Dr. C.N.B. In this opinion, Dr. C.N.B. presented an opinion that the diagnostic criteria for diabetes had distinct categories for Type II diabetes and endocrinopathic diabetes, and that the gastric surgery led to dumping syndrome and in turn to a type of endocrinopathic diabetes. Dr. C.N.B. specifically ruled out the existence of Type II diabetes. However, Dr. A.R.F. indicates that such dumping syndrome led to Type II diabetes, a result that appears to be inconsistent with the medical information provided by Dr. C.N.B. The clinical records clearly indicate that the veteran has consistently been diagnosed with non insulin dependent diabetes (Type II), which includes Dr. A.R.F.'s own treatment records. In addition, none of the cited literature provides evidence or draws the conclusion that such changes would result in any type of diabetes. Dr. C.N.B. did review the entire medical record. However, his opinion is inconsistent with the diagnoses provided since 1989 and, although he claims otherwise, his position is not supported by the medical literature that he provides. As noted above, none of the present literature actually links diabetes with gastric surgery. In addition, the veteran has consistently been diagnosed with Type II/non insulin dependent diabetes mellitus. This diagnosis was even provided by the internal medicine physicians that provided favorable opinions to the veteran. There is no clinical record since 1989 that has noted a diagnosis of endocrinopathic diabetes, even after the veteran's repeated assertions that his gastric surgery resulted in his diabetes. Thus, it was not just the VA physicians that did not consider a diagnosis of endocrinopathic diabetes appropriate, but also the veteran's multiple private physicians, apparently all internal medicine physicians, that consistently provided a diagnosis of Type II diabetes. Dr. C.N.B.'s opinion is therefore viewed as unreliable and unconvincing. Finally, Dr. A.A.C. has provided a favorable opinion. However, this opinion does not appear to be based on a review of the entire medical history as contained in the claims file. In addition, the opinion amounts to no more than a conclusion without any significant reasons and bases for Dr. A.A.C.'s findings. The VA opinions of August 1993, January 1999, and October 2002 all attribute the onset of the veteran's diabetes mellitus to deficient insulin production in the islet cells of the pancreas and/or a relative insensitivity of the insulin receptors to the circulating insulin and the onset of peripheral neuropathy to diabetes mellitus. Regardless of Dr. C.N.B.'s allegations, these physicians clearly had access to the veteran's medical history contained in the claims file in preparation of these opinions. These physicians commented that the etiology of the veteran's non-insulin dependent diabetes mellitus did not differ significantly from that found in most instances of adult-onset diabetes mellitus. But, they conclusively rejected any assertion that the veteran's prior gastrointestinal surgical procedures precipitated the onset of diabetes mellitus more than two decades later. The Board finds that the August 1993, January 1999, and October 2002 opinions are more persuasive than the opinions of Drs. O.H.C., A.R.F., C.N.B., and A.A.C., as to the etiology of the claimed disability. The VA physician's that provided opinions in January 1999 and October 2002 were specialist in gastrointestinal and hepatology disorders. The opinions favorable to the veteran were provided predominately by internal medicine physicians. While probative, the Board finds that the greater probative weight should be given to the VA gastrointestinal and hepatology specialist that had reviewed the entire/contemporaneous medical history contained in the claims file. While Dr. C.N.B. provided a detailed opinion, as noted above, this opinion was inconsistent with the clinical records/diagnoses and the cited medical literature. In addition, while Dr. C.N.B. claims to be a "neuro-radiologist;" however, there is no evidence that he has any specialty in neurology or internal medical. His noted credentials merely cite him as an associate professor of radiology and nuclear medicine. Again, the gastrointestinal and hepatology specialists' opinions have greater probative value and weight than Dr. C.N.B.'s opinion. Also of record is a document with an "ADVA" stamp, dated in June 1993, and the opinion of Dr. R.T. dated in October 2000. These documents are of no probative value since they do not address diabetes mellitus. The Board has reviewed all the evidence and finds that the most probative evidence is the VA specialists' unequivocal statements that establish that there is no relationship. The preponderance of the evidence establishes that the veteran's diabetes mellitus and associated peripheral neuropathy are unrelated to his 1958 and 1963 gastrointestinal surgical procedures. The Board concludes that compensation under the provisions of 38 U.S.C.A. § 1151 (West 1991) is not warranted and there is no doubt to be resolved. ORDER Compensation under the provisions of 38 U.S.C.A. § 1151 (West 1991) for diabetes mellitus with peripheral neuropathy is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs