Citation Nr: 1106485 Decision Date: 02/16/11 Archive Date: 02/28/11 DOCKET NO. 08-25 353 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for type II diabetes mellitus. 2. Entitlement to service connection for hypertension. REPRESENTATION Appellant represented by: Alabama Department of Veterans Affairs ATTORNEY FOR THE BOARD K. J. Kunz, Counsel INTRODUCTION The Veteran served on active duty from January 1980 to December 1992. This appeal comes before the Board of Veterans' Appeals (Board) from a March 2007 rating decision by the Montgomery, Alabama Regional Office (RO) of the United States Department of Veterans Affairs (VA). In that decision, the RO denied service connection for type II diabetes mellitus and for hypertension. In December 2009, the Board remanded the case to the RO for the development of additional evidence. The Board is satisfied that there has been substantial compliance with the remand directives. The Board will proceed with review. See Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. During service, the Veteran had some elevated blood sugar levels, but received no diagnosis of diabetes. 2. Type II diabetes mellitus of recent onset was diagnosed in 2004. 3. Elevated blood pressure, including above normal range diastolic pressure, was measured on multiple occasions during service. CONCLUSIONS OF LAW 1. Type II diabetes mellitus was not incurred or aggravated in service, and may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2010). 2. Hypertension was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Review of the claims file reveals compliance with the notice and duty to assist requirements. 38 U.S.C.A. § 5100, et seq. (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2010). A letter dated in June 2006, before the March 2007 rating decision that is on appeal, advised the Veteran of the evidence needed to substantiate his claims, and explained what evidence VA was obligated to obtain or assist him in obtaining and what information or evidence he was responsible for providing. 38 U.S.C.A. § 5103(a) (West 2002); Quartuccio v. Principi, 16 Vet. App. 183 (2002). That letter also apprised the Veteran both of the disability rating and downstream effective date elements of his claim. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). As the RO issued the notice letter prior to initially adjudicating the Veteran's claim in March 2007, the preferred sequence, the Board finds no timing error in the provision of the notice. Pelegrini v. Principi, 18 Vet. App. 112 (2004). With regard to VA's duty to assist claimants, VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran, including service treatment records and post service treatment records. A private medical record in the file indicates that the Veteran had received treatment for hypertension at Skyland Medical Center. In the December 2009 remand, the Board instructed the RO to seek records of that treatment. In a January 2010 letter, the VA Appeals Management Center (AMC) asked the Veteran to complete a release form to authorize Skyland Medical Center to provide those records to VA. The Veteran did not return a completed release form; so VA was not able to request those records from the medical center. Also in the 2009 remand, the Board requested a VA medical examination, with review of the claims file and opinions as to the likely etiologies of the Veteran's diabetes and hypertension. The Board specified that the Veteran be informed that the failure to report for the examination, without good cause, might have adverse consequences on his claims. In the January 2010 letter, the AMC provided such notice to the Veteran. The first examination scheduled for the Veteran was cancelled by VA personnel because it was scheduled to be performed at a VA Medical Center VAMC where the Veteran is an employee. An examination was scheduled at a different VAMC. The Veteran did not report for that examination. VA offices, including the Board, the AMC, and the RO, have taken reasonable steps to obtain relevant evidence. The Board therefore is satisfied that there was substantial compliance with the December 2009 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). VA has complied with the duties to notify and assist the Veteran, and the Board will adjudicate the issues on appeal based on the evidence of record. Diabetes The Veteran essentially contends that his current type II diabetes mellitus began during service or is a continuation or progression of a condition that was present during service. He notes that service medical records showed an elevated blood sugar level. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for a 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). Certain chronic disabilities, including diabetes mellitus, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107. In a December 1979 medical examination for entrance into service, urinalysis was negative for sugar. At a periodic physical examination in November 1986, the Veteran's fasting blood sugar level was slightly elevated. On repeat examination, the fasting blood sugar level was within normal limits. In a July 1992 examination, the Veteran's fasting blood sugar level was 114 mg/dl, slightly above the expected range limit of 111 mg/dl. On a repeat test, the level was 112 mg/dl. Follow-up was recommended with regard to the blood sugar level. The claims file does not contain any medical evidence from the year following the Veteran's service. After service, a private physician who began treating the Veteran in October 2004 diagnosed new onset diabetes mellitus in December 2004. Records from 2004 through 2006 show ongoing treatment for diabetes. In his June 2006 claim, the Veteran reported that he had high blood sugar found in service in 1985 or 1986, and that he had diabetes diagnosed in 2005. In a July 2007 statement, the Veteran asserted that stress from his duties during service was instrumental in the gradual development of his diabetes. He stated that his duties handling nuclear weapons were very demanding, exacting, and stressful. In an August 2008 statement, the Veteran argued that his service medical records showed the beginnings of diabetes. The Veteran had slightly high blood sugar levels during service, and follow-up was recommended. However, he was not diagnosed with diabetes during service or the year following service. When a clinician diagnosed diabetes in 2004, the clinician described the diabetes as having a fairly recent onset. Considering the medical finding in 2004 that the diabetes was of recent onset, the preponderance of the evidence is against the claim that the blood sugar levels in service represented the beginnings of the current diabetes. The Board therefore denies service connection for the Veteran's diabetes. Hypertension The Veteran essentially contends that his current hypertension was present during service or is a continuation of a condition that was present during service. Hypertension is among the listed chronic disabilities that VA presumes have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. In a December 1979 medical examination for entrance into service, the Veteran's blood pressure was 120/78. On examination in November 1986, his blood pressure was 150/92. He was referred for follow-up. In a five day blood pressure check in December 1986, the five day averages were 132/89 in the right arm and 134/92 in the left arm. He had a further blood pressure follow-up in January 1987. He reported that he did not have chest or respiratory symptoms. He stated that he smoked, and that he had a family history of heart disorders. Three day averages of his blood pressure were 134/90 in the right arm and 132/98 in the left arm. The examiner's impression was normotensive at this time. The examiner recommended that the Veteran avoid added salt and high salt content foods. Records from 1988, 1989, and 1992 reflect the Veteran's reports that he smoked one pack of cigarettes per day. In a July 1992 check-up, the clinician recommended that the Veteran decrease his sodium intake and stop smoking. The claims file does not contain any medical evidence from the year following the Veteran's service. Records of post-service medical treatment show that by October 2004 the Veteran was on medication for hypertension. Records from 2004 through 2006 show ongoing treatment for hypertension. In his June 2006 claim, the Veteran indicated that he had hypertension found in service in 1985 or 1986, and that he currently had hypertension. In a July 2007 statement, the Veteran asserted that stress from his service duties handling nuclear weapons was instrumental in the gradual development of his hypertension. In an August 2008 statement, the Veteran argued that his service medical records showed the beginnings of hypertension. Clinicians who treated the Veteran in service ordered follow-up in response to the Veteran's blood pressure readings. One clinician determined on follow-up that the Veteran was normotensive for the present, and no diagnosis of hypertension was made. However, clinicians recommended lifestyle measures to try to control the Veteran's blood pressure. On many of the measurements, the Veteran's diastolic pressure was over 90, the limit for normal. Resolving reasonable doubt in favor of the Veteran's claim, the Board will accept that the elevated blood pressure readings during service constituted the early manifestation of the hypertension that was diagnosed after service. The Board therefore grants service connection. ORDER Entitlement to service connection for type II diabetes mellitus is denied. Entitlement to service connection for hypertension is granted. ____________________________________________ MICHAEL MARTIN Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs