Citation Nr: 1301602 Decision Date: 01/15/13 Archive Date: 01/23/13 DOCKET NO. 02-08 880A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for diabetes mellitus, including as secondary to renal glycosuria. 2. Entitlement to service connection for arteriosclerotic cardiovascular disease, including as secondary to diabetes mellitus. 3. Entitlement to an initial evaluation in excess of 20 percent for the service-connected renal glycosuria. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD L. J. N. Driever INTRODUCTION The Veteran had active service from August 1961 to August 1965. These claims come before the Board of Veterans' Appeals (Board) on appeal from March 1999 and May 2006 rating decisions of the RO. The Veteran testified at hearings held before a Hearing Officer at the RO in March 2006 and before a Veterans Law Judge (VLJ) in Washington, D.C. in January 2008. In February 2008 and May 2010, the Board remanded these matters to the RO for additional development of the record. In a letter dated in March 2012, the Board informed the Veteran that the VLJ who conducted the hearing in January 2008 had retired and that, if he wished, he could testify at a hearing before another VLJ. As the Veteran did not respond, the Board will proceed in adjudicating the claims remaining on appeal. A review of the Virtual VA paperless claims processing system reveals no additional documents pertinent to the claims being decided. The claim for an initial evaluation in excess of 20 percent for the service-connected renal glycosuria is being remanded to the RO via the Appeals Management Center in Washington, D.C. FINDINGS OF FACT 1. The Veteran is not presumed to have been exposed to herbicides during his period of active service. 2. Diabetes mellitus is not related to the Veteran's active service, including his in-service renal glycosuria, and did not manifest to a compensable degree within a year of his discharge from service. 3. Arteriosclerotic cardiovascular disease is not related to the Veteran's active service or a service-connected disability and did not manifest to a compensable degree within a year of his discharge from service. CONCLUSIONS OF LAW 1. Diabetes mellitus was not incurred in or aggravated by active service and may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1111, 1112, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. Arteriosclerotic cardiovascular disease was not incurred in or aggravated by active service, may not be presumed to have been so incurred, and is not proximately due to or the result of service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1111, 1112, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist Upon receipt and prior to consideration of most applications for VA benefits, VA is tasked with satisfying certain procedural requirements outlined in the Veterans Claims Assistance Act of 2000 (VCAA) and its implementing regulations. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The United States Court of Appeals for Veterans Claims (Court) has mandated that VA ensure strict compliance with the provisions of the VCAA. Quartuccio v. Principi, 16 Vet. App. 183 (2002). A. Duty to Notify The VCAA and its implementing regulations provide that VA must notify a claimant and his representative, if any, of the information and medical or lay evidence not previously provided to the Secretary that is necessary to substantiate a claim. As part of the notice, VA is to specifically inform the claimant and his representative, if any, of which portion of the evidence the claimant is to provide and which portion of the evidence VA will attempt to obtain on the claimant's behalf. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012). These notice requirements apply to all five elements of a service connection claim, including: (1) veteran status; (2) existence of disability; (3) a connection between service and disability; (4) degree of disability; and (5) effective date of disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006). Notice under the VCAA must be provided a claimant prior to an initial unfavorable decision by the agency of original jurisdiction. Pelegrini v. Principi (Pelegrini II), 18 Vet. App. 112, 119-20 (2004). The RO provided the Veteran VCAA notice on the claims being decided by letters dated in July 2002, August 2003, November 2003, March 2006, May 2008, July 2008, September 2008 and May 2010. These letters satisfy the content requirements noted above. The RO notified the Veteran of the evidence needed to substantiate the claims, identified the type of evidence that would best do so, notified him of VA's duty to assist and indicated that it was developing his claims pursuant to that duty. The RO also provided the Veteran all necessary information on disability ratings and effective dates. The RO identified the evidence it had requested and/or received in support of the Veteran's claims and the evidence it was responsible for securing. Per instructions on February 2008 and May 2010 Remands, the RO informed the Veteran that it planned to request pertinent records of diabetes treatment provided the Veteran furnished VA written authorization to do so. The RO pointed out that it was the Veteran's responsibility to ensure VA's receipt of all pertinent evidence. During the Veteran's January 2008 hearing, a former VLJ provided additional notice by pointing out that evidence was needed indicating that the abnormal findings shown in service represented diabetes. The RO sent some of the notice letters after initially deciding the Veteran's claims. The RO cured this timing defect later however by readjudicating these claims in a supplemental statement of the case issued in December 2011. Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007). B. Duty to Assist VA is also to assist a claimant in obtaining evidence necessary to substantiate a claim, but such assistance is not required if there is no reasonable possibility that it would aid in substantiating the claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2012). The RO made reasonable efforts to identify and obtain relevant records in support of the Veteran's claims. Specifically, it secured and associated with the claims file all evidence the Veteran identified as being pertinent to the claims being decided. It sought identification of any pertinent treatment records dated after service, but before the 1990s. The RO also afforded the Veteran a hearing before the Board, during which the Veteran testified as to the onset of the disabilities at issue in this decision, and VA examinations, during which examiners discussed the etiology of the disabilities. In addition, the RO obtained a medical opinion in support of the claim for service connection for diabetes mellitus. II. Analysis The Veteran seeks service connection for diabetes mellitus and arteriosclerotic cardiovascular disease. According to written statements submitted during the course of this appeal, including in October 1998, December 1999, January 2000, June 2000, October 2001, July 2002, August 2002, February 2003, April 2003, August 2003, November 2004, May 2005, June 2005, July 2006, July 2007, August 2007, March 2008, November 2008 and May 2012, and his hearing testimony, presented in March 2006 and January 2008, he first manifested findings of diabetes mellitus during service, including that of renal glycosuria, which later developed into arteriosclerotic heart disease. A medical professional reportedly diagnosed the Veteran with diabetes mellitus, characterized as permanent, during service in April 1963, but did not notify him of the diagnosis, including on discharge in August 1965 (was told that his kidneys spilled sugar into his urine at a lower level than normal, thereby disqualifying him from service, but that the condition was benign and nothing to worry about). The Veteran asserts that, in 1966, he began to experience problems commonly associated with this condition, including slower healing times for cuts and insect bites (from four weeks to three months) and that, thereafter, medical professionals diagnosed uncontrollable hypertension (1969), elevated cholesterol and triglycerides (1971), unstable angina and coronary artery disease (1976 or 1977), and an enlarged fatty liver (1983, and diabetes mellitus (1994), a myocardial infarction (1995), congestive heart failure (1996), and a loss of feeling in his right lower extremity due to acute neuropathic cachexia (2000). The Veteran refers to literature showing that many diabetics, particularly those who exercise, eat well and lead a healthy lifestyle, are undiagnosed for years. He argues that he was one of these individuals and that, while he exhibited signs of diabetes mellitus in service, a medical professional first confirmed the condition in 1993. He asserts that this literature also indicates that, once one has diabetes mellitus, it is permanent, requiring control. He also refers to favorable medical evidence of record, including a private physician's written opinion relating his diabetes mellitus to service. The Veteran has submitted copies of articles, including from the internet, generally supporting his assertions, describing the nature, prevalence and complications of pre-diabetes and diabetes mellitus and the nature of renal glycosuria, and discussing VA's treatment guidelines for diabetic veterans. The Veteran has also submitted a letter from his former spouse, dated in May 2005, who noted that, from August 1966 to June 1997, the Veteran developed skin infections from poison ivy, insect bites and cuts and often became sleepy after eating a meal. Allegedly, after he developed hypertension in approximately 1969, he became very health conscious, prompting him to watch his diet and attempt to walk and hike on weekends and play golf with his business associates. In his November 2008 written statement, the Veteran alternatively contends that, while stationed at McGuire Air Force Base in the 1960s and working in airborne radar and navigational equipment repair, he was required to troubleshoot and repair equipment on C118s, C135s and C130s, aircraft used to transport Agent Orange. Allegedly, these duties exposed him to this herbicide, which is presumed associated with diabetes mellitus. The Board acknowledges the Veteran's statements of record and the medical literature and documents he has submitted in support of these claims. As will be discussed, considered collectively, the preponderance of the evidence is against the claim of service connection for diabetes mellitus and arteriosclerotic cardiovascular disease, the latter on a secondary basis. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military, naval or air service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). Service connection may be granted for any disease diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in active service. 38 C.F.R. § 3.303(d) (2012). To prevail on the issue of service connection, there must be competent and credible evidence of (1) a current disability; (2) in-service occurrence or aggravation of a disease or injury; and (3) a nexus between the in-service injury or disease and the current disability. See generally Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Subsequent manifestations of a chronic disease in service, however remote, are to be 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 diagnosis including the word "chronic." Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). To establish continuity after discharge, the evidence must demonstrate the following: (1) condition "noted" during service; (2) post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology. Id. at 498 (holding that, on the question of whether the veteran has a chronic condition since service, the evidence must be medical unless it relates to a condition as to which, under case law, lay observation is competent). Once evidence is determined to be competent, its credibility must be evaluated. Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency, a legal concept focusing on whether testimony may be heard and considered, and credibility, a factual determination focusing on the probative value of the evidence). Service connection may be presumed for certain chronic conditions such as diabetes mellitus and cardiovascular-renal disease, including hypertension (term applies to combination involvement of the type of arteriosclerosis, nephritis and organic heart disease), if a veteran served continuously for 90 days or more during a period of war or during peacetime after December 31, 1946, and the condition manifested to a degree of 10 percent within one year of the date of discharge. 38 U.S.C.A. §§ 1101, 1112(a), 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2012). In some circumstances, a disease associated with exposure to certain herbicide agents may be presumed to have been incurred in service even though there is no evidence of that disease during the period of service at issue. 38 U.S.C.A. § 1116(a) (West 2002); 38 C.F.R. §§ 3.307(a)(6), 3.309(e) (2012). In this regard, a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during such service to an herbicide agent unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 U.S.C.A. § 1116(f) (West 2002). "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii); see Haas v. Nicholson, 20 Vet. App. 257 (2006), rev'd sub nom. Haas v. Peake, 525 F.3d 1168 (Fed Cir. 2008), cert. denied, 129 S. Ct. 1002 (2009) (holding that VA's requirement that a veteran must have been present within the land borders of Vietnam - must have actually set foot therein - at some point in the course of duty in order to be entitled to a presumption of herbicide exposure constitutes a permissible interpretation of 38 U.S.C.A. § 1116(a)(1) and 38 C.F.R. § 3.307(a)(6)(iii). A veteran who never went ashore from the ship on which he served in the Vietnam coastal waters is not entitled to presumptive service connection. Id. Type 2 diabetes mellitus (also known as type II diabetes mellitus or adult-onset diabetes) is included in 38 C.F.R. § 3.309(e) as a disease that has been associated with herbicide exposure. Service connection may also be granted when a claimed disability is found to be proximately due to or the result of a service-connected disability, or when any increase in severity (aggravation) of a nonservice-connected disease or injury is found to be proximately due to or the result of a service-connected disability. See 71 Fed. Reg. 52,744 (2006) (codified at 38 C.F.R. § 3.310 (2012)); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). A. Diabetes Mellitus The Veteran had active service from August 1961 to August 1965, which is during the Vietnam era. According to his DD Form 214, he did not have any foreign service, including in the Republic of Vietnam. He is therefore not presumed to have been exposed to herbicides during service. According to the report of physical condition dated on April 25, 1963, a medical professional diagnosed the Veteran with diabetes mellitus during service. It was indicated that "sugar diabetes" represented a defect that necessitated special consideration in regard to the Veteran's duty assignment and that any required limitation was to be considered permanent pending referral to a Medical Board. The form was prepared in response to the results of a March 1963 urinalysis that was ordered after the Veteran reported having a 16 pound weight gain and showed that he had a small trace of sugar in his urine. After additional testing, including a glucose tolerance test (fasting blood sugar of 108 then 163 (after a half hour), 159 (an hour later) and 138 (two hours later)), conducted during four visits in April 1963, a medical professional referred the Veteran for a Physical Evaluation Board, determined that a temporary profile was necessary and recommended that he be instructed on diabetes mellitus and diet. During an evaluation conducted in May 1963, an examiner noted a history of diabetes mellitus in April 1963. He referred the Veteran for an opinion as to whether the glycosuria then found on testing represented diabetes mellitus or renal glycosuria. In June 1963, a medical professional responded that the Veteran had a low renal threshold for glucose and that, in this type of renal glycosuria, abnormal glucose tolerance might develop, but was not diagnostic of diabetes mellitus at that point. The individual suggested no therapy in response to the diagnosis, found the Veteran fit for duty, and suggested a repeat glucose tolerance test in one year. At the separation examination in May 1965, the examiner noted a history of sugar in the urine in 1963, indicated that diets were recommended, and found that the Veteran had had no recurrences. In the 1990's, the Veteran was diagnosed as having diabetes mellitus and, since then, he has continued to receive treatment for the condition. The question is thus whether it is related to the Veteran's active service, including the abnormal in-service findings/glucosoria. There are various forms of evidence in the claims file addressing the etiology of the Veteran's diabetes mellitus. For instance, in a November 1998 email exchange, an online diabetes educator offered an opinion in response to an inquiry from the Veteran regarding whether diabetes mellitus could be cured or controlled for thirty years after an initial diagnosis in his twenties and return again in his fifties after years of no treatment or diet. The response was that, because diabetes mellitus did not go away once it was manifested, it was either ignored or controlled. A specialist in internal medicine, endocrinology and nutrition treated the Veteran from 1994 to 1998 and offered a favorable opinion. In letters dated in August 1999 and March 2002, the physician noted that, in 1994, the Veteran was clearly shown to be diabetic with hypertriglyceridemia and a known history of coronary artery disease, angina syndrome, hypercholesterolemia and hypertension. He also noted that the Veteran had renal glycosuria in service and that there was a known relationship between glycosuria and the presence of diabetes mellitus. He added that, over the years, the Veteran exhibited manifestations of syndrome X, including obesity, hyperlipidemia, insulin resistance and a tendency toward earlier than average coronary artery disease. In a letter dated in October 2004, the physician elaborated that, according to criteria that existed when the Veteran was in service, the results of his April 1963 glucose tolerance test were normal, but the criteria had since changed. According to this change, any fasting number over 100, which the Veteran had in service (108), is now considered abnormal and would be labeled as impaired fasting glucose. The physician added that the Veteran went on to develop insulin-dependent diabetes and multiple complications and that it was known medically that individuals with a low renal threshold for glucose might have glucosuria in the absence of demonstrable diabetes mellitus on testing, but that the greatest number of those individuals eventually developed diabetes mellitus. The physician concluded that there is no justification for denying service connection for diabetes mellitus as it was first discovered during military service and any decision to the contrary would represent an inaccurate interpretation of the facts. Also of record is an undated article from The Merck Manual of Diagnosis and Therapy on Renal Glucosuria, which the Veteran submitted in support of this claim in 2002. According to this article, two cases of isolated renal glucosuria occur for every 1000 cases of glucosuria due to diabetes mellitus. The transport maximum was reduced and glucose escaped into the urine. Renal glucosuria was asymptomatic and without serious sequelae, but a few individuals developed diabetes mellitus, a condition that could only be ruled out by establishing the cause of the glucosuria. A VA examiner, offered another opinion in the report of a VA examination conducted in July 2003. He noted an in-service history of renal glycosuria and a normal glucose tolerance test and ruled out a relationship between the Veteran's diabetes mellitus and renal glycosuria. He explained that the latter condition without a positive glucose tolerance test was not indicative of diabetes mellitus. Similarly, in a report of a VA examination conducted in December 2003, another VA examiner opined that the onset of the Veteran's diabetes mellitus could not be traced back to his military service. In a report of a VA examination conducted in February 2004, a VA examiner found that the Veteran had had diabetes mellitus since 1990 that was not related to his benign, in-service renal glycosuria. He based this opinion on: (1) the Veteran's in-service glucose tolerance test, which showed a 2 hour post-prandial or post-glucose tolerance plasma level of 138 mg/dl (normal being less than 140mg/dl.); and (2) a finding that there is no evidence that renal glycosuria with normal glucose tolerance was a precursor or indicator of diabetes mellitus. The examiner concluded that there is no reason to believe that his current condition could be related to the benign in-service finding. In a report of a VA examination conducted in April 2006, a VA examiner, a specialist in endocrinology, diabetes mellitus and metabolism opined that, according to the present day standard of practice, neither renal glycosuria, nor normal glucose tolerance testing was a precursor or indicator of diabetes mellitus and that the Veteran would not be diagnosed with diabetes mellitus. He also noted that the standard of practice in effect when the Veteran was in service would not have led to a diagnosis of pre-diabetes as such a diagnosis did not exist. In a report of VA examination conducted in November 2006, a VA examiner noted that an opinion in terms of a relationship between renal glycosuria and diabetes mellitus was questionable and that the numbers used to diagnose diabetes in 1963 were higher than they were today. She acknowledged the in-service presence of renal glycosuria, but noted that, because the record did not show the exact amount of glucose the Veteran had in his blood in 1963 or whether he was even tested, she could not assume such a relationship. In a March 2007 VA addendum opinion, in response to the question of whether the Veteran's decrease in kidney function was due to his service-connected renal glucosuria or nonservice-connected diabetes mellitus, another VA physician concluded that he could not address this issue without resorting to mere speculation. The VA treatment records dated since 2001 include comments by multiple treatment providers indicating that the Veteran had had diabetes mellitus since the 1960's. In all cases, these comments are based on, or are a reiteration of, the Veteran's reported medical history. An August 2012 report a medical expert opinion, obtained by VA in response to the obviously conflicting medical evidence of record, ruled out a relationship between the Veteran's diabetes mellitus and service, including the renal glycosuria, on both direct and aggravation bases. It also indicates that the Veteran's abnormal in-service findings were not sufficient to support a diagnosis of diabetes mellitus during active service or within a year of the Veteran's discharge from service. The medical expert, a physician, based his unfavorable opinion on a review of the claims file, the in-service medical history noted hereinabove and an acknowledgement that the criteria for diagnosing diabetes have changed since the 1960's. He also based his opinion on the following findings: (1) Renal glucosuria was not a precursor of diabetes mellitus and did not herald the future development of diabetes mellitus; (2) The Veteran was diagnosed with diabetes mellitus in the 1990's, nearly 30 years after service; (3) Diabetes mellitus was based on laboratory criteria, now more stringent than in 1963, and, based on the glucose reading of 108 in service, the Veteran did not meet the criteria then or now in effect for a diagnosis of diabetes mellitus (presently must have fasting glucose of 126 or higher or a random glucose of 200 or higher); (4) There is no evidence of a causal factor in service, which could be associated with the development or aggravation of the Veteran's diabetes mellitus; (5) If there had been such a causal factor, the Veteran's diabetes mellitus would have developed and been diagnosed much earlier; (6) Although there could be a delay between the development of diabetes mellitus and its diagnosis, the delay was rarely more than a few years as health problems from the uncontrolled diabetes began to develop; and (7) Renal glycosuria does not cause or aggravate diabetes mellitus and had nothing to do with elevated blood sugars seen in diabetics, but rather represented a low renal threshold for spilling sugar into urine. Under Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993), the Board must assess the credibility and weight to be attached to medical opinions. Provided these opinions include adequate statements of reasons or bases, the Board may favor one opinion over another. Wray v. Brown, 7 Vet. App. 488 (1995). An assessment or opinion by a health care provider is never conclusive and is not entitled to absolute deference. Rather, the Board must consider the weight to be placed on an opinion depending upon the reasoning employed to support the conclusion and the extent to which the physician reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). An examination that does not take into account the records of prior medical treatment is neither thorough nor fully informed. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). A bare transcription of lay history, unenhanced by additional comment by the transcriber, does not constitute competent medical evidence merely because the transcriber is a health care professional, see LeShore v. Brown, 8 Vet. App. 406,409 (1995), and a medical professional is not competent to opine as to matters outside the scope of his expertise. Id (citing Layno v. Brown, 6 Vet. App. 465, 469 (1994)). A medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty. Bloom v. West, 12 Vet. App. 185, 187 (1999). A medical opinion is inadequate when unsupported by clinical evidence, see Black v. Brown, 5 Vet. App. 177, 180 (1995), and a medical opinion based on an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458,461 (1993). In this case, the Board assigns limited weight to the reports of VA examinations conducted in December 2003 and November 2006 and the March 2007 opinion as they do not include statements of reasons or bases that was adequate. The Board assigns very little evidentiary weight to the reports of VA examinations conducted in April 2006 and November 2006. Although the reports of these examinations include enlightening findings that refute Dr. Levine and confirm the August 2012 medical expert, therein, the examiners refrain from specifically offering an opinion as to whether the diabetes and in-service renal glycosuria are related. The Board assigns greater weight to the July 2003 and February 2004 reports of VA examinations. Although succinct, they are supported by rationale. The Board assigns even greater weight to Dr. Levine's opinion as it is based on an accurate accounting of the Veteran's medical history, the clinical evidence of record and a review of the claims file and supported by rationale. Moreover, Dr. Levine is particularly trained to provide such an opinion, being specialized in endocrinology. Unfortunately, one of the primary bases of his favorable opinion is a finding that the glucose readings the Veteran exhibited during service are now considered representative of impaired fasting glucose. The preponderance of the evidence - specifically, three other medical opinions - refute this assertion. The Board thus assigns the greatest weight to the August 2012 medical expert's opinion. It is the most probative as it is based on a review of the claims file, an accurate accounting of the Veteran's medical history, the clinical evidence of record and a review of the claims file. Moreover, it is supported by rationale that two other VA examiners have confirmed. The November 1998 email from the diabetes educator and the articles the Veteran have submitted in support of this claim are also probative and establish that, in some cases, an individual with renal glycosuria will develop diabetes mellitus. These articles, however, do not specifically address the Veteran's case. The Veteran's assertions thus represent the only remaining evidence relating his diabetes mellitus to his active service. Not being specially trained in the medical field, however, the Veteran is not competent to offer an opinion on causation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (finding a layperson not competent to offer an opinion regarding a medical question when that question may not be resolved through lay observation). Based primarily on the medical expert's August 2012 opinion, the Board finds that the Veteran's diabetes mellitus is not related to his active service. Based on the fact that this condition was not diagnosed until the 1990s, the Board also finds that it did not manifest to a compensable degree within a year of his discharge from service. In light of the foregoing, the Board concludes that diabetes mellitus was not incurred in or aggravated by service and may not be presumed to have been so incurred. A claimant is responsible for presenting evidence in support of his claim for benefits under laws administered by VA. VA is responsible for considering all such evidence, lay and medical. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA is to give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The preponderance of the evidence in this case is against the Veteran's claim. The benefit of the doubt rule is thus not for application and the claim must be denied. B. Arteriosclerotic Cardiovascular Disease The Veteran has submitted articles and a November 1998 email from a diabetes mellitus educator indicating that, in many cases, coronary artery disease, a form of arteriosclerotic cardiovascular disease, develop as secondary to diabetes mellitus. In addition, the RO has associated with the claims file treatment records generally indicating that the Veteran has complications of diabetes mellitus, including certain cardiovascular abnormalities. Dr. Levine's August 1999 and October 2004 letters and a report of VA examination conducted in December 2001, specifically related the heart disease to his diabetes mellitus. The Board thus finds the Veteran's assertion of such a relationship objectively confirmed. Given its decision regarding the Veteran's diabetes mellitus, however, the Board's finding in this regard does not entitle the Veteran to a grant of service connection on a secondary basis. There is also no evidence of record to support a grant of service connection on a direct or presumptive basis. The Veteran does not contend that his heart disease initially manifested during service and all pertinent medical evidence establishes the condition developed many years after service, following his diabetes diagnosis. Inasmuch as arteriosclerotic cardiovascular disease is not related to the Veteran's active service or a service-connected disability, the Board concludes that it was not incurred in or aggravated by active service. Inasmuch as it manifested many years after the Veteran's discharge from service, the Board also concludes that it may not be presumed to have been incurred in service. The preponderance of the evidence in this case is against the Veteran's claim. The benefit of the doubt rule is thus not for application and the claim must be denied. ORDER Service connection for diabetes mellitus is denied. Service connection for arteriosclerotic cardiovascular disease, including as secondary to service-connected disability, is denied. REMAND In May 2010, the Board remanded the claim for increase to the RO in order to have the Veteran examined to determine the severity of the service-connected renal glycosuria. The Board explained that there were insufficient medical findings of record to rate this condition pursuant to the rating schedule. The Board further explained that there were documents of record dated in 2007 showing that the Veteran had been prescribed compression stockings for edema of the lower extremities and medication for hypertension in the past, but no commentary on whether the edema was transient or slight and associated with the renal glycosuria or whether the hypertension was presently controlled by continuous medication. The RO partially complied by scheduling the Veteran for an examination, but the Veteran failed to report. It is unclear whether the Veteran was aware of the RO's action in this regard as there is no letter in the claims file notifying the Veteran of the date and time of the scheduled examination. (The RO sent the Veteran VCAA notice that did not mention an examination.) Such notice was necessary as the VLJ who remanded this claim in May 2010 emphasized that, after scheduling the examination, the RO must associate a copy of the notification, including the address where the notice was sent, with the claims file. The VLJ likely emphasized this instruction given that the claims file conflicts regarding the current address on record. A Board remand imposes upon VA's Secretary a concomitant duty to ensure compliance with the terms of the remand. When the RO fails to comply with the Board's orders set forth therein, the Board must insure subsequent compliance by returning the claims file for completion of the previously requested action. Stegall v. West, 11 Vet. App. 268 (1998). Given the lack of compliance with the Board's very specific May 2010 remand instructions, this claim must again be remanded for the purpose of documenting notification of a scheduled VA examination of the Veteran's renal glycosuria. Accordingly, this remaining matter is REMANDED to the RO for the following action: 1. The RO should take all indicated action in order to verify the Veteran's current address. 2. The RO then should undertake to have the Veteran scheduled for a VA examination to determine the current severity of the service-connected renal glycosuria. The RO should notify the Veteran in writing of the time and date of the scheduled hearing and associate with the claims file a copy of that notification. The Veteran should be notified of the consequences of any failure to report to the examination without good cause. The VA examiner should review the claims file, to indicate in writing in his report that he did so, conduct any tests deemed necessary, and provide an accurate and fully descriptive assessment of the extent of the service-connected renal glycosuria. Such assessment should include a discussion of whether the Veteran has transient or slight or persistent edema associated with his renal glycosuria and/or hypertension presently controlled by continuous medication. 3. The RO should review the examination report to ensure that it includes all requested information and, if not, return it to the examiner for correction. 4. After completing all indicated development the RO should readjudicate claim for increase in light of all the evidence of record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished a fully responsive Supplemental Statement of the Case and afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the RO for the purpose of appellate disposition. The Board intimates no opinion as to the ultimate disposition in this case, but reminds the Veteran that he has the right to submit additional evidence and argument on the remanded claim. Kutscherousky v. West, 12 Vet. App. 369, 372 (1999). This claim must be afforded expeditious treatment. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs