Citation Nr: 1319789 Decision Date: 06/19/13 Archive Date: 06/27/13 DOCKET NO. 08-38 327 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for diabetes mellitus, type II. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD M. Moore, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1977 to January 1998, including service in Southwest Asia. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, that, in pertinent part, denied service connection for diabetes mellitus, type II (DM). He subsequently perfected his appeal for DM in October 2008. While the Veteran did request a Travel Board hearing on his October 2008 VA Form 9, in subsequent communications received in October 2008 and November 2009, he indicated that he longer desired a Board hearing. Accordingly, the Veteran's hearing request is considered withdrawn. See 38 C.F.R. § 20.704(e) (2012). The issue of service connection was initially on appeal. In an April 2009 rating decision, the St. Petersburg RO granted service connection for hypertension. This grant of service connection is considered a full grant of the benefits on appeal for the Veteran's hypertension claim. As such, the claim of entitlement to service connection for hypertension is no longer before the Board. See generally Grantham v. Brown, 114 F.3d 115 (Fed. Cir. 1997); Barrera v. Gober, 122 F.3d 1030 (Fed. Cir. 1997). The March 2008 rating decision also denied a reopening of the claim for service connection for organic heart disease. The Veteran initiated his appeal by filing a notice of disagreement in April 2008. The RO/AMC eventually furnished him with a Statement of the Case on that issue in March 2011. However, the Veteran did not perfect his appeal by filing a substantive appeal, to include a VA Form 9. The issue of whether new and material evidence has been submitted to reopen the claim for service connection for organic heart disease is therefore not the subject of appellate review. FINDING OF FACT The Veteran's currently diagnosed DM had its onset in service or within one year of his service discharge. CONCLUSION OF LAW DM was incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309(a) (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims file. While the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Veterans Claims Assistance Act of 2000 (VCAA) As to the Veteran's claim for service connection for DM, this claim has been granted, as discussed below. Any error related to the VCAA is moot. See 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2011); 38 C.F.R. § 3.159 (2011); Mayfield v. Nicholson, 19 Vet. App. 103, (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Merits of the Claim The Veteran alleges that he currently suffers from DM as a result of service. Specifically, he claims that his DM, although not diagnosed at that time, first began in service. Alternatively, he claims that his DM is due to various exposures that he had while serving in Southwest Asia, including depleted uranium. Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002). However, that an injury or disease occurred in service is not enough; there must also be a chronic disability resulting from that injury or disease. If there is no showing of the chronic disability during service, then a showing of continuous symptoms after service is required to support a finding of chronicity. See 38 C.F.R. § 3.303(b) (2012). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. See 38 C.F.R. § 3.303(d) (2012). In order to establish service connection for a disability, there must be (1) evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and certain diseases, such as DM, become manifest to a degree of 10 percent or more within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. See 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). Initially, the Board acknowledges the Veteran's assertion, referenced above, that his DM may be related to various exposures during his service in Southwest Asia, including depleted uranium. However, the medical evidence supports a grant of service connection for DM on grounds other than exposure to depleted uranium or other substances, as discussed in detail below. Any discussion of the relationship between the Veteran's in-service exposures and subsequent DM is irrelevant. A review of the medical evidence reveals that the Veteran has been diagnosed with DM. As such, the first element of Hickson is met. A review of the service treatment records reveals that the Veteran's retirement physical showed elevated triglycerides, which is considered an early sign of DM as discussed below. Therefore, the second element of Hickson is met. The remaining question is whether a medical nexus exists between the Veteran's in-service elevated triglycerides and his current DM diagnosis. In May 2013, the Board obtained a medical opinion from the Veterans Health Administration (VHA). The VHA endocrinologist found that it was more likely than not that the Veteran's DM was related to his military service. Although there were no blood work values to support a diagnosis of DM in service or within a year of separation, she opined that the Veteran's in-service elevated triglycerides were an early sign of DM. She further stated that dyslipidemia in the absence of thyroid dysfunction, as is the case here, often precede abnormal glucose and insulin findings in DM patients. Although the Veteran did not exhibit symptoms of DM in service, she indicated that patients can have DM and remain asymptomatic for extended periods of time, even years. In light of the lack of laboratory data to refute a diagnosis of DM in service or within a year of discharge and the supportive findings of hypertriglyceridemia/dyslipidemia in service, she concluded that it was more likely than not that the Veteran's DM began in service or within a year of discharge. The Veteran was previously afforded a VA examination in November 2011. The examiner concluded that the Veteran's DM was not related to service because there were no blood work results that met strict criteria for a diagnosis of DM until 2005, seven years after the Veteran's separation from service. However, she failed to address the elevated triglyceride values in service or provide an opinion on whether they were any early signs of the Veteran's subsequent DM diagnosis. Further, she did not address the diagnoses of DM as early as 2000 in the Veteran's private treatment records. The Board is free to favor one medical opinion over another as long as it provides an adequate basis for doing so. See Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). In this case, the Board finds the May 2013 VHA endocrinologist's opinion to be at least as probative as the November 2011 VA examiner's opinion. Both physicians reviewed the claims file and provided rationales to support their conclusions. Moreover, the May 2013 VHA endocrinologist provided a more thorough explanation as to the relationship between dyslipidemia and later development of DM - a theory that the November 2011 examiner failed to discuss. Accordingly, the Board finds that the medical evidence in this case is, at minimum, in equipoise regarding the question of whether the Veteran's current DM is related to his military service. As such, the benefit-of-the-doubt will be conferred in the Veteran's favor and his claim for service connection for DM is granted. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to service connection for diabetes mellitus, type II, is granted. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs