Citation Nr: 0810340	
Decision Date: 03/28/08    Archive Date: 04/09/08

DOCKET NO.  05-34 264	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in 
Philadelphia, Pennsylvania


THE ISSUES

1.  Entitlement to service connection for diabetes mellitus, 
type II.

2.  Entitlement to service connection for a heart condition, 
to include sinus bradycardia.


REPRESENTATION

Appellant represented by:	Disabled American Veterans


ATTORNEY FOR THE BOARD

W. Donnelly, Associate Counsel




INTRODUCTION

The veteran served on active duty with the United States Air 
Force from September 1965 to December 1968, and with the 
United States Marine Corps from March 1977 to August 2001.

This matter comes before the Board of Veterans' Appeals 
(Board) on appeal from a January 2005 rating decision by the 
Philadelphia, Pennsylvania, Regional Office (RO) of the 
Department of Veterans Affairs (VA), which denied service 
connection for type II diabetes mellitus and a heart 
condition.  The veteran field a Notice of Disagreement (NOD) 
in March 2005, and a Statement of the Case (SOC) was issued 
in August 2005.  The veteran perfected his appeal with the 
timely filing of a VA Form 9, Appeal to Board of Veterans' 
Appeals, in October 2005.  A Supplemental SOC (SSOC) was 
issued in September 2006.  The veteran has submitted 
additional evidence since that time, along with a waiver of 
Agency of Original Jurisdiction (AOJ) consideration.


FINDINGS OF FACT

1.  Type II diabetes mellitus was not incurred during active 
duty service, nor was it manifested to a compensable degree 
within the first post-service year, the veteran was not 
exposed to herbicides.

2.  There is no currently diagnosed chronic heart disability.


CONCLUSIONS OF LAW

1.  Service connection for diabetes mellitus, type II, is not 
warranted.  38 U.S.C.A. §§ 1110, 1112, 1116, 1131, 5103, 
5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 
3.159, 3.303, 3.307, 3.309 (2007).

2.  Service connection for a heart condition, to include 
sinus bradycardia, is not warranted.  38 U.S.C.A. §§ 1110, 
1131, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. 
§§ 3.102, 3.159, 3.303 (2007).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

VA's Duties to Assist and Notify

As provided for by the Veterans Claims Assistance Act of 2000 
(VCAA), the United States Department of Veterans Affairs (VA) 
has a duty to notify and assist claimants in substantiating a 
claim for VA benefits.  38 U.S.C.A. §§ 5100, 5102, 5103, 
5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. 
§§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007).  

Upon receipt of a complete or substantially complete 
application for benefits, VA is required to notify the 
claimant and his representative, if any, of any information, 
and any medical or lay evidence, that is necessary to 
substantiate the claim.  38 U.S.C.A. § 5103(a); 38 C.F.R. 
§ 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002).  
Proper notice from VA must inform the claimant of any 
information and evidence not of record that is necessary to 
substantiate the claim.  VA should inform the appellant of 
what information and evidence VA will seek to provide, and 
what information and evidence the claimant is expected to 
provide.  Proper notice should invite the claimant to provide 
any evidence in her or his possession that pertains to the 
claim in accordance with 38 C.F.R. § 3.159(b)(1).  This 
notice must be provided prior to an initial unfavorable 
decision on a claim by the agency of original jurisdiction 
(AOJ).  Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 
2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004).  

In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. 
Court of Appeals for Veterans Claims held that, upon receipt 
of an application for a service-connection claim, 38 U.S.C. 
§ 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the 
information and the evidence presented with the claim and to 
provide the claimant with notice of what information and 
evidence not previously provided, if any, will assist in 
substantiating, or is necessary to substantiate, each of the 
elements of the claim, including notice of what is required 
to establish service connection and that a disability rating 
and an effective date for the award of benefits will be 
assigned if service connection is awarded.  In this case, 
although the notice provided did not address either the 
rating criteria or effective date provisions that are 
pertinent to the appellant's claim, such error was harmless 
given that service connection is being denied, and hence no 
rating or effective date will be assigned with respect to the 
claimed conditions.

Here, the VCAA duty to notify was satisfied by way of a 
letter(s) sent to the appellant in February 2003 that fully 
addressed all four notice elements and was sent prior to the 
initial AOJ decision in this matter.  The letter informed the 
appellant of what evidence was required to substantiate the 
claims and of the appellant's and VA's respective duties for 
obtaining evidence.  The appellant was also asked to submit 
evidence and/or information in his possession to the AOJ.

VA additionally has a duty to assist the veteran in the 
development of the claim.  This duty includes assisting the 
veteran in the procurement of service medical records and 
pertinent treatment records and providing an examination when 
necessary.  38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159.  

The Board finds that all necessary development has been 
accomplished, and therefore appellate review may proceed 
without prejudice to the appellant.  See Bernard v. Brown, 4 
Vet. App. 384 (1993).  The RO has obtained VA treatment 
records from VA Medical Center (VAMC) Altoona and complete 
service treatment records, and has requested, and received, 
copies of private medical records from Dr. SJP and Dr. JSM on 
the veteran's behalf.  The veteran submitted copies of 
service medical records and statements from Dr. SJP.  The 
appellant was afforded a VA medical examination in December 
2004.  Significantly, neither the appellant nor his or her 
representative has identified, and the record does not 
otherwise indicate, any additional existing evidence that is 
necessary for a fair adjudication of the claim that has not 
been obtained.  Other evidence of record, particularly 
private orthopedic records and VA examination reports, 
addresses issues not under consideration here.  Hence, no 
further notice or assistance to the appellant is required to 
fulfill VA's duty to assist the appellant in the development 
of the claim.  Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 
281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 
Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 
Vet. App. 183 (2002).

Service Connection

Service connection will be granted if it is shown that the 
veteran suffers from a disability resulting from personal 
injury suffered or disease contracted in the line of duty, or 
for aggravation of a preexisting injury suffered or disease 
contracted in the line of duty, during active military 
service.  38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303.  
Disorders diagnosed after discharge will still be service 
connected if all the evidence, including that pertinent to 
service, establishes that the disease was incurred in 
service.  38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 
F.3d 1039, 1043 (Fed. Cir. 1994).  Some chronic diseases may 
be presumed to have been incurred in service, if they become 
manifest to a degree of ten percent or more within the 
applicable presumptive period.  38 U.S.C.A. §§ 1101(3), 
1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a).

In the absence of proof of a present disability there can be 
no valid claim.  Brammer v. Derwinski, 3 Vet. App. 223, 225 
(1992).  Service connection requires a finding of the 
existence of a current disability and a determination of a 
relationship between that disability and an injury or disease 
incurred in service.  Watson v. Brown, 4 Vet. App. 309, 314 
(1993); see also Boyer v. West, 210 F.3d 1351, 1353 (Fed. 
Cir. 2000).  To establish service connection, there must be:  
(1) a medical diagnosis of a current disability; (2) medical 
or, in certain cases, lay evidence of in-service occurrence 
or aggravation of a disease or injury; and (3) medical 
evidence of a nexus between an in-service injury or disease 
and the current disability.  Hickson v. West, 12 Vet. 
App. 247, 252 (1999), citing Caluza v. Brown, 7 Vet. 
App. 498, 506 (1995), aff'd 78 F.3d 604 (Fed. Cir. 1996).  

A layperson is generally not capable of opining on matters 
requiring medical knowledge.  Routen v. Brown, 10 Vet. 
App. 183, 186 (1997).  See also Bostain v. West, 11 Vet. 
App. 124, 127 (1998) citing Espiritu v. Derwinski, 2 Vet. 
App. 492 (1992) (a layperson without the appropriate medical 
training and expertise is not competent to provide a 
probative opinion on a medical matter, to include a diagnosis 
of a specific disability and a determination of the origins 
of a specific disorder).  

Competent medical evidence means evidence provided by a 
person who is qualified through education, training, or 
experience to offer medical diagnoses, statements, or 
opinions.  Competent medical evidence may also mean 
statements conveying sound medical principles found in 
medical treatises.  It also includes statements contained in 
authoritative writings, such as medical and scientific 
articles and research reports or analyses.  38 C.F.R. 
§ 3.159(a)(1).  Competent lay evidence means any evidence not 
requiring that the proponent have specialize d education, 
training, or experience.  Lay evidence is competent if it is 
provided by a person who has knowledge of facts or 
circumstances and conveys matters that can be observed and 
described by a lay person.  38 C.F.R. § 3.159(a)(2).  

A disorder will be service connected if the evidence of 
record, regardless of its date, shows that the veteran had a 
chronic disorder in service or during an applicable 
presumption period, and that the veteran still has the same 
disorder.  With chronic disease shown as such in service (or 
within the presumptive period under § 3.307) so as to permit 
a finding of service connection, 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, as 
distinguished from merely isolated findings or a diagnosis 
including the word "chronic."  38 C.F.R. § 3.303(b).  A 
determination as to whether medical evidence is needed to 
demonstrate that a veteran presently has the same condition 
he or she had in service or during a presumption period, or 
whether lay evidence will suffice, depends on the nature of 
the veteran's present condition (e.g., whether the veteran's 
present condition is of a type that requires medical 
expertise to identify it as the same condition as that in 
service or during a presumption period, or whether it can be 
so identified by lay observation).  Savage v. Gober, 10 Vet. 
App. 488, 494-97 (1997).  

If the disorder is not chronic, it will still be service 
connected if the disorder is observed in service or an 
applicable presumptive period, continuity of symptomatology 
is demonstrated thereafter, and competent evidence relates 
the present disorder to that symptomatology.  Continuity of 
symptomatology is required only where the condition noted 
during service (or in the presumptive period) is not, in 
fact, shown to be chronic or where the diagnosis of 
chronicity may be legitimately questioned.  Again, whether 
medical evidence or lay evidence is sufficient to relate the 
current disorder to the in-service symptomatology depends on 
the nature of the disorder in question.  Savage, 10 Vet. App. 
at 497.  

In determining whether service connection is warranted for a 
disability, 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 the claim, in which 
case the claim is denied.  38 U.S.C.A. § 5107; Gilbert 
v. Derwinski, 1 Vet. App. 49 (1990).  When there is an 
approximate balance of positive and negative evidence 
regarding any issue material to the determination, the 
benefit of the doubt is afforded the claimant.   


Diabetes Mellitus, Type II

The Board notes that although the RO developed for evidence 
of herbicide exposure in Vietnam, and discussed possible 
entitlement to service connection for diabetes mellitus, type 
II, based on the presumption related to Agent Orange 
exposure, the veteran has in fact stated repeatedly that he 
never served in Vietnam and he had never been exposed to 
Agent Orange, to his knowledge.  Therefore, possible 
entitlement to service connection for diabetes mellitus as 
due to herbicide exposure is not considered herein.

The veteran has instead argued that he is entitled to direct 
service connection based on the initial manifestation of 
signs and symptoms in service, and alternatively that he is 
entitled to the benefit of presumptive service connection due 
to diagnosis within the first post service year.

Here, however, service medical records reflect no diagnosis 
of or treatment for diabetes mellitus, type II.  Periodic 
examinations for flight status repeatedly noted no sugar in 
the urine, and the veteran denied such when asked.  While, 
blood tests revealed fluctuating glucose levels, it is 
unclear from the record which, if any were fasting bloodwork.  
In 1990, a the glucose level was 110, which is the end of the 
"normal" range indicated on the reports.  A 113 reading in 
1993 was considered high.  It dropped to the high 90's until 
1998, when a still-normal reading of 107 was noted.  At no 
time did any provider indicate a diabetic or prediabetic 
condition existed.

Dr. JSM, an orthopedist who treated the veteran in November 
2001 and January 2002, reported in treatment records that the 
veteran was "negative for diabetes."

VA treatment records from January 2002 to February 2003 
reveal no diagnosis of or complaints related to diabetes.  In 
June 2002, blood glucose was 100.  However, in February 2003, 
the veteran informed doctors that dosage on a blood pressure 
medication had been increased because his "sugar was 
elevated."  Doctors did not indicate any problems with the 
sugar levels.  A VA examination in April 2001 did not 
indicate any blood sugar problems or complaints.

Dr. SJP, the veteran's primary care physician, has treated 
the veteran from separation in August 2001 to the present.  
Treatment records reveal elevated blood glucose levels.  In 
January 2002, a reading of 114 was obtained, prompting the 
doctor to notify the veteran and state that there was a 
"modest elevation in your blood glucose.  This could 
represent the earliest form of diabetes.  This needs to be 
monitored periodically."  The doctor did not, however, 
diagnose diabetes.  In January 2004, a level of 131 was 
shown.  The doctor noted impaired glucose tolerance/diabetes 
mellitus type II and recommended diet and exercise.  In 
January 2005 correspondence, Dr. SJP stated that he had 
treated the veteran since 2001 for hyperglycemia.  He stated 
that this disorder was present in service, noting elevated 
blood sugar of 110 in July 1990, and other unspecified 
reading over 100 since that time.  The doctor stated that 
over the past year, the veteran met the clinical definition 
of diabetes, as his last four blood sugars had been between 
126 and 134.  Dr. SJP felt treatment for diabetes, beyond 
current diet and exercise was only a year or two off.

The veteran submitted a statistical analysis of his 
laboratory results showing a purported upward trend in blood 
glucose levels from his time in service to the present.  This 
includes notice that the America Diabetes Association (ADA) 
considers a blood glucose level of 125 to be evidence of 
diabetes.  From 100 to 125 is considered by the ADA as pre-
diabetic.

The medical evidence clearly indicates that diabetes was not 
diagnosed until 2004.  At no time while the veteran was in 
service was diabetes diagnosed, nor does the medical evidence 
in any way support a conclusion that diabetes should have 
been diagnosed.  The veteran's blood sugar readings in 
service were, with a single exception in 1993, within the 
normal range noted on all lab reports.  The "upward trend" 
the veteran cites is not persuasive, as the actual test 
results show that the veteran reduced his blood sugars from 
high points in the early 1990's to lows in the late 90's.  
Readings did rise again closer to separation, but they were 
lower than or equal to the highest readings in service.  
Consistent increases in blood sugar did not appear until 
after separation from service.

Diabetes was not diagnosed until early 2004, more than two 
years after separation.  This is beyond the applicable one 
year presumptive period, and hence service connection under 
38 C.F.R. § 3.307 is not applicable.  Direct service 
connection is also not warranted, as there is no diagnosis of 
the disease in service.  Dr. SJP diagnoses the pre-2004 
condition not as diabetes, but as hyperglycemia.  Being 
"pre-diabetic" or hyperglycemic does not qualify as the 
first manifestation or onset of the of the disease.  It is a 
demonstration of a risk factor, not a diagnosis.  In the 
absence of a diagnosis in service or evidence of the first 
manifestation of the actual disease in service, the claim 
must be denied.





Heart Condition

The veteran claims service connection for a heart condition 
manifested by abnormal electrocardiograms (ECG).  He is 
diagnosed with, and service connected for, long standing 
hypertension.

Service medical records reveal repeated findings of sinus 
bradycardia on ECG, from 1984 forward, though not on every 
test.  Sinus bradycardia is a slow heartbeat.  A left axis 
deviation was also regularly noted.  In 1998, a "left 
arterial enlargement" was reported, but this notation was 
not made on prior or subsequent testing.  No heart disease or 
dysfunction was diagnosed, and the veteran was not 
disqualified from flight status.

Dr. SJP's treatment records include no findings or diagnoses 
of a heart disease or disability.  A 2003 ECG continued to 
show sinus bradycardia and a left axis deviation.  In 
September 2005, Dr. SJP stated that he was following the 
"mild cardiac conduction abnormality" and felt that some 
slight progression had been shown over the years.  The 
veteran was not under treatment for a cardiac condition, 
however, and the doctor did "not know if he will ever need 
treatment for the cardiac problem."

VA treatment records from January 2002 to February 2003 show 
no diagnosis of any heart condition or disease, and testing 
shows a normal rhythm.

At a December 2004 VA heart examination, the veteran 
complained of dyspnea after running at a fast pace on a 
treadmill for 5 to 10 minutes.  He denies chest pains, 
dizziness, or syncope.  No heart abnormality was noted on 
testing.  The examiner indicated that a sinus bradycardia was 
present, but was unrelated to hypertension or diabetes.

The Board finds that service connection for a heart condition 
is not warranted, as there is currently no diagnosed disease 
or disability subject to service connection.  Sinus 
bradycardia, as found in repeated objective testing since 
1984, is not a disease or disability; it is a laboratory 
finding which falls, in the absence of underlying disease, 
within the normal variation of medical experience.  Sinus 
bradycardia is especially common is well trained athletes and 
others in good physical condition.  Even the veteran's 
treating physician has indicated that there is no current 
heart disability, stating that no treatment is required and 
may never be.

In the absence of a current disability or disease, service 
connection must be denied.


ORDER

Service connection for diabetes mellitus, type II, is denied.

Service connection for a heart condition, to include sinus 
bradycardia, is denied.



____________________________________________
DENNIS F. CHIAPPETTA
Veterans Law Judge, Board of Veterans' Appeals




 Department of Veterans Affairs