Citation Nr: 1325400 Decision Date: 08/12/13 Archive Date: 08/16/13 DOCKET NO. 09-26 328 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUE Entitlement to service connection for diabetes mellitus, to include as secondary to service-connected hypothyroidism. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. Erdheim, Counsel INTRODUCTION The Veteran served on active duty from January 1988 to April 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah. This is a Virtual VA claims file. Instead of paper, a highly secured electronic repository is used to store and review every document involved in the claims process. The use of this system allows VA to leverage information technology in order to more quickly and accurately decide a Veteran's claim for benefits. In July 2011, the Veteran testified before the Board via videoconference. In February 2013, the Board requested and obtained a medical opinion on the matter through Veterans Health Administration (VHA) directives. FINDING OF FACT Diabetes mellitus is not shown to be causally or etiologically related to any disease, injury, or incident during service, did not manifest within one year following separation from service, and was not caused or aggravated by the service-connected hypothyroidism. CONCLUSION OF LAW Diabetes mellitus was not incurred in or aggravated by the Veteran's active duty military service and was not secondary to a service-connected disability. 38 U.S.C.A. §§ 1101, 1112, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). In the instant case, the Board finds that VA has satisfied its duty to notify through an April 2008 letter. The claim was then adjudicated in July 2008, and most recently in an April 2011 supplemental statement of the case. Mayfield, 444 F. 3d at 1333-34. Relevant to the duty to assist, the Veteran's service treatment records, VA treatment records, and private records have been obtained and considered. The Veteran has not identified any additional, outstanding records necessary to decide her pending appeal. As this is a paperless claim, the Board has reviewed the Veteran's paperless Virtual VA claims file. Additionally, the Veteran was afforded VA examinations in June 2010 and January 2011, with an additional VHA opinion received in February 2013, in order to adjudicate her service connection claim. Those examinations, particularly the February 2013 VHA opinion, addressed the etiology of her diabetes mellitus on a direct and secondary basis. The Board finds that the proffered opinions were based on current or past interviews with the Veteran and review of the record, including multiple physical examinations. From these examinations, clear conclusions with reasoned medical explanations were reached and are sufficient to decide the Veteran's claim. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of her claim. II. Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection may also 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 service. 38 C.F.R. § 3.303(d). Direct service connection may be granted with medical evidence of a current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307, (ii) present manifestations of the same chronic disease, and (iii) evidence of continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Such includes the Veteran's claim for diabetes mellitus. Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases to a degree of 10 percent within one year from the date of termination of such service, including diabetes mellitus, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). During the course of this appeal, VA amended 38 C.F.R. § 3.310 effective October 10, 2006), to implement the decision in Allen. See 71 Fed. Reg. 52,744 -47 (Sept. 7, 2006). The existing provision at 38 C.F.R. § 3.310 (b) was moved to sub-section (c). The amended 38 C.F.R. § 3.310 (b) institutes additional evidentiary requirements and hurdles that must be satisfied before aggravation may be conceded and service connection granted. To whatever extent the revised regulation may be more restrictive than the previous one, the Board will afford the Veteran review under both the old and new versions. See VAOPGCPREC 7-2003 (Nov. 19, 2003). The Veteran's main contention is that her diabetes mellitus was either caused or aggravated by her service-connected hypothyroidism. Service treatment records are negative for any indication of a diagnosis of diabetes. The records reflects that she was diagnosed with hypothyroidism in 1995, while in service, and was diagnosed with diabetes mellitus in 2005, 8 years following separation from service. Shortly after her diagnosis of diabetes, in September 2005, her physician concluded that the Veteran had probable type 2 diabetes, but with onset at age 40 in a fairly thin female with no family history of diabetes, there was a question of slow-onset type 1. Her blood sugar were fairly well-controlled. Her highest blood sugar had been 217 since her diagnosis. Her thyroid was palpable but not enlarged. She had a TSH level of 2.543. In November 2005, her TSH level was at 3.164. Her diabetes mellitus showed improvement on Metformin. Her Synthroid was increased from 50 to 75 mcg. In February 2006, her diabetes mellitus was in fairly good control as reflected in her range of blood sugars postprandially and consistent with a HbA1c at .64. Her hypothyroidism was in a euthyroid status. In September 2009, her diabetes was considered to have good glucose control. There were no diabetic complications. Her hypothyroidism was euthyroid on replacement. In March 2010, her TSH was 1.549. Her hypothyroidism was asymptomatic. Her glucose fasting ranges ran from 102 to 159 and her HbA1c was 6.4 %. The Veteran's private physician, Dr. H., at many times during the appeal period, has stated that the Veteran's diabetes was "documented to occur in association with or as a result of hypothyroidism." In June 2010, another treating physician, Dr. K., stated that there was an association between hypothyroidism and diabetes. He explained that hypothyroidism could have significant effects on glucose levels because it prevented the thyroid gland from producing enough hormones to stimulate metabolism, slowing the body's processes and effecting insulin production. That complication lead to diabetes and it was possible such was the Veteran's case. On the other hand, two VA examiners have stated that there was no link between hypothyroidism and diabetes. In June 2010, a VA examiner stated that there was no known casual relationship between the two diseases, and, in January 2011, a VA examiner agreed that there was no casual relationship and further stated that the Veteran was on adequate thyroid replacement medication resulting in a euthyroid state. There was no extreme hypothyroid state to cause diabetes mellitus. However, the Veteran contends that the hormonal imbalance of her thyroid, over time, has aggravated her diabetes. She contends that her elevated TSH levels cause her A1c levels to elevate and that her thyroid-stimulating hormone must be tightly controlled in order to keep her A1c levels low. She submitted laboratory data showing that in October 2010, her TSH level was 2.774 and her HbA1c percentage was 6.9, and that in January 2011, her TSH level was 1.242 and her HbA1c percentage was 6.5. In February 2013, the Board obtained a VHA opinion on the matter because of the conflicting medical opinions. An endocrinologist reviewed the record and concluded that it was less likely than not that the Veteran's hypothyroidism caused or aggravated her diabetes mellitus. The examiner clarified that although there was an epidemiologic association between diabetes and hypothyroidism, in that once a person has one autoimmune disorder the chances of developing a second is higher than in the general population, it would be a mistake to say that diabetes causes hypothyroidism or vice versa. The two conditions simply tended to occur at a higher frequency in the same individuals because of a related mechanism. There was absolutely no evidence that hypothyroidism caused diabetes mellitus. With regard to aggravation, the examiner explained that there was very little evidence to support that theory. While hypothyroidism could increase the risk of hypoglycemia in individuals treated with insulin, in a patient who was taking just Metformin, like the Veteran, such an outcome would not occur. Furthermore, the effects of untreated clinical hypothyroidism were of little or no consequence in individuals with subclinical hypothyroidism or treated hypothyroidism, as in the case of the Veteran. The evidence reviewed, showing a progression of hypothyroidism and increase in Synthyroid, was typical and reflected good surveillance and response to her disease. With proper hormone treatment, the metabolic abnormalities of hypothyroidism were reversed and completely normal physiology was restored. The diagnosis of diabetes mellitus at a time when the Veteran's TSH was minimally elevated was only coincidental and did not support the hypothesis of aggravation. The examiner found it to be significant that the records demonstrated excellent management of diabetes and hypothyroidism since the 1995 diagnosis of hypothyroidism and the 2005 diagnosis of diabetes, thus causation and aggravation were not shown. To that extent, her A1c values were excellent in 2011. First, the Board finds that service connection for diabetes mellitus on a presumptive basis is not warranted because diabetes was not diagnosed within one year following service separation. 38 C.F.R. § 3.307, 3.309. Next, the Board finds that service connection for diabetes is not warranted on a direct basis. To that extent, there is no evidence of diabetes while the Veteran was serving on active duty. Rather her diabetes was diagnosed in 2005, approximately eight years following service separation. There is additionally no medical evidence or competent medical nexus opinion to support the contention that her diabetes began while she was on active duty. Moreover, the Veteran has not contended that her diabetes began in service. Accordingly, absent a chronic disability in service, continuous symptoms since service, or a medical opinion relating her diabetes with service, the preponderance of the evidence is against the claim for service connection for diabetes mellitus on a direct basis. Nor is service connection for diabetes warranted on a secondary basis, as the competent, credible, and probative medical evidence weighs against a finding that her service-connected hypothyroidism caused or aggravated her diabetes. In that regard, the Board places great probative weight on the February 2013 VHA opinion, which comports with the June 2010 and January 2011 VA opinions, rather than on the two private opinions. For one, Dr. H.'s opinions, that the Veteran's diabetes and hypothyroidism were documented to occur in association with or as a result of one another, have not been accompanied by any medical rationale. Instead, they are only conculsory in nature. Therefore, the Board places less probative weight on these opinions because they do not explain how the Veteran's hypothyroidism caused or aggravated her diabetes, especially in light of the probative 2013 VHA opinion which thoroughly explained that there was no causative relationship between the two diseases, but only a coincidental one due to the nature of autoimmune disorders. Then, although Dr. K. does provide a rationale for the medical opinion reached, that hypothyroidism could have significant effects on glucose levels which would aggravate diabetes mellitus, it does not appear that the Veteran's particular medical history supports that opinion. The physician did not state with any affirmation that such was the case with the Veteran, but only stated that such a phenomenon could occur. Thus, although the physician's medical explanation comports with the 2013 VHA examiner's explanation in terms of how hypothyroidism might affect glucose levels, such does not seem to be the case in this instance. Rather, as explained by the 2013 VHA examiner, the Veteran's hypoglycemia has been well-controlled on medication and the medication restored her thyroid to a normal state. Therefore, there was no indication that her hypothyroidism had affected her metabolic system or her diabetes. By contrast, the Board finds that the 2013 VHA opinion is highly probative because the examiner provided a thoroughly reasoned explanation as to how hypothyroidism would affect diabetes and ruled out such affects in this particular case for many reasons, mainly that the Veteran' s hypothyroidism had not been shown to be uncontrolled. The 2013 VHA opinion is also probative in stating that there was no causative relationship between hypothyroidism and diabetes because that finding completely comports with the other two VA examiners' opinions, finding that there was no link between the conditions. As the VHA examiner clarified, although the two conditions were more likely to be seen in one individual, there was no medical support to state that one caused the other, especially in the case of hypothyroidism causing diabetes. Accordingly, for the above reasons, the Boards finds that the competent, credible, and probative medical evidence of record weighs against the Veteran's claim, and thus, her claim for service connection on a secondary basis must be denied. While the Veteran contends that her diabetes was caused or aggravated by her service or a service-connected disability, the Board accords her statements regarding the etiology of this disorder less probative value as she is not competent to opine on such a complex medical question. It is true that lay evidence may be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). While the Veteran is competent to state her symptoms and dates of diagnosis, she is not competent to state that her currently diagnosed diabetes was caused or aggravated by service or hypothyroidism because she does not have the requisite knowledge and skills to determine such etiology. Such a conclusion requires medical skill and review of the physical findings in service and since service. The same is true on a secondary basis. As the Board finds that the preponderance of the evidence is against this claim, the benefit of the doubt doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107. Service connection for diabetes on a direct or secondary basis is denied. ORDER Service connection for diabetes mellitus is denied. ____________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs