Citation Nr: 1337383 Decision Date: 11/15/13 Archive Date: 11/26/13 DOCKET NO. 10-25 300 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for back disability. 2. Entitlement to service connection for heart disability. 3. Entitlement to service connection for hypertension. 4. Entitlement to service connection for type 2 diabetes mellitus. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD K. J. Kunz, Counsel INTRODUCTION The Veteran served on active duty from July 1962 to October 1963. This appeal comes before the Board of Veterans' Appeals (Board) from an August 2008 rating decision by the Chicago, Illinois Regional Office (RO) of the United States Department of Veterans Affairs (VA). In that decision, the RO denied service connection for back disability, heart disability, hypertension, and type 2 diabetes mellitus. In December 2012, the Board remanded these issues for the development of additional evidence. With respect to those issues, the Board is satisfied that there has been substantial compliance with the remand directives. The Board will proceed with review of those issues. See Stegall v. West, 11 Vet. App. 268 (1998). Previously, in 1993, the Veteran submitted a claim for VA disability compensation benefits under 38 U.S.C.A. § 1151 for a back disability. He contended that back disability was caused by back surgery performed at the VA Medical Center in October 1990. The RO denied that claim, and in March 2000 the Board denied the claim on appeal. The Veteran's present back disability claim is a claim for direct service connection, that is, a claim that current back disability was incurred or aggravated in service. Direct service connection claims are considered under different statutes than 38 U.S.C.A. § 1151 claims. Therefore it is not necessary to reopen any previously denied claim before considering the direct service connection claim. The Board has reviewed both the Veteran's paper claims file and the Veteran's file on the Virtual VA electronic file system, to ensure a total review of the evidence. FINDINGS OF FACT 1. The current back disability, including lumbosacral spine and disc degeneration, did not become manifest earlier than several years after service, nor before a post-service back injury, and there is no credible evidence it is related to military service in any way. 2. As no use or presence of tactical herbicides in Guam in or around the early 1960s is recorded, exposure of the Veteran to herbicides during service is not found. 3. Arteriosclerotic heart disease did not become manifest during service or the year following separation from service, and is not attributable to treatment with Dexamyl during service, or to any other service disease or event. 4. Hypertension did not manifest during service or the year following service, and did not develop as a result of Dexamyl use during service, or to any other service disease or event. 5. Type 2 diabetes mellitus did not manifest during service or the year following service, and did not develop as a result of Dexamyl use during service, or to any other service disease or event. CONCLUSIONS OF LAW 1. Current back disability, including lumbosacral spine and disc degeneration, was not incurred or aggravated in service, and may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1112, 1131, 1137, 5107 (West 2001); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). 2. Current heart disability, including arteriosclerotic heart disease, was not incurred or aggravated in service, and may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1112, 1116, 1131, 1137, 5107 (West 2001); 38 C.F.R. §§ 3.303, 3.307, 3.309. 3. Current hypertension was not incurred or aggravated in service, and may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 4. Current type 2 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. §§ 1112, 1116, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist a claimant in the development of a claim for VA benefits. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). The notice requirements of the VCAA require VA to notify the Veteran of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has stated that the requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). Insufficiency in the timing or content of VCAA notice is harmless, however, if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). The RO provided the Veteran with VCAA notice in a February 2008 letter, issued before the August 2008 rating decision on the claims on appeal. In that letter, the RO addressed the information and evidence necessary to substantiate claims for service connection. The RO informed the Veteran how VA assigns effective dates. The letter also addressed who was to provide the evidence. The Veteran's claims file (including information on paper and in electronic form) contains service treatment records, records of post-service treatment and examinations, and statements from the Veteran and persons who know him. The Veteran has had VA medical examinations that adequately address the claims that the Board is deciding at this time. Examinations were performed by qualified clinicians who reviewed the Veteran's claims file and provided findings and opinions relevant to those claims. In the December 2012 remand, the Board instructed that the AMC or RO (1) obtain the Veteran's United States Social Security Administration (SSA) records and (2) develop evidence regarding the Veteran's contention that he was exposed to herbicides containing dioxin during service in Guam. The Veteran's SSA records have been associated with the Veteran's claims file. The AMC obtained information from the United States Department of Defense (DOD), and made a finding, regarding the contention of herbicide exposure in Guam. The Board is satisfied that there has been substantial compliance with the remand directives. Therefore, no additional remand is needed with regard to the claims for service connection for back disability, heart disability, hypertension, and diabetes. The Board may proceed with review of those issues on their merits. See Stegall v. West, 11 Vet. App. 268 (1998). The Veteran was notified and aware of the evidence needed to substantiate his claims, as well as the avenues through which he might obtain such evidence, and the allocation of responsibilities between the Veteran and VA in obtaining such evidence. The Veteran has actively participated in the claims process by providing evidence and argument. Thus, he was provided with a meaningful opportunity to participate in the claims process, and he has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication nor to have caused injury to the Veteran's interests. See Pelegrini, 18 Vet. App. at 121. Therefore, any such error is harmless, and does not prohibit consideration of those claims on their merits. See Conway, 353 F.3d at 1374, Dingess, 19 Vet. App. 473; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Back Disability The Veteran essentially contends that he has a back disability that began in service. Service connection may be established 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. Service connection for certain specifically listed chronic diseases, including arthritis, may be established based upon a legal presumption by showing that it manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. The Court has explained that, in general, service connection requires (1) evidence of a current disability; (2) medical evidence, 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 Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Under 38 C.F.R. § 3.303(b), if a chronic disease or injury is shown in service, subsequent manifestations of the same chronic disease or injury at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. The provisions of 38 C.F.R. § 3.303(b) have been interpreted as an alternative means of establishing service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Nonetheless, service connection also may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The Board must assess the credibility and weight of all the 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 claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 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 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. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Veteran's service treatment records do not reflect any complaints regarding his back. The claims file does not contain any evidence regarding the condition of the Veteran's back during the year following his separation from service. Private medical records reflect that in July 1978 the Veteran fell and had onset of persistent back pain radiating into the right leg. Treating clinicians diagnosed a ruptured disc at L5-S1. He did not report a prior history of back pain or any military injury. In September 1978, the Veteran underwent spine surgery, including lumbar laminectomy at L5-S1 on the right. Records of VA treatment of the Veteran from 1981 through 2000 reflect a long history of back problems, with symptoms of low back pain radiating into the lower extremities. Treatment records reflect the history of low back injury and surgery in the late 1970s. In November 1981, the Veteran was treated for an episode of more severe low back pain and right leg numbness following heavy lifting and other heavy work. In August 1987, he was seen for acute low back sprain after lifting a copying machine. In VA treatment in September 1990, the Veteran reported that, beginning around 1976, he experienced back pain and lower extremity weakness. He noted having had back surgery in about 1977. He related that about three weeks before the September 1990 treatment he moved boxes and then developed low back pain and lower extremity numbness and weakness. From September 1990, VA clinicians found that the Veteran had right foot drop. Imaging in October 1990 showed a herniated L4-L5 disc and central canal stenosis at that level. In late October the Veteran underwent back surgery which included L4-L5 laminectomy and discectomy. The Veteran underwent a State of Michigan disability evaluation in January 1992. At that time he reported having constant pain in his back and legs, with right foot drop. He stated that he had initial back injury in 1978, treated with surgery, and a reinjury in July 1990, followed by surgery in October 1990. In February 1992, SSA found that the Veteran had been disabled for Social Security purposes since October 1990. SSA listed a primary diagnosis of coronary artery disease and a secondary diagnosis of degenerative disc disease. In May 1993, the Veteran sought VA disability compensation for a back disorder and foot drop. He asserted that the disorders began with the October 1990 VA back surgery. The Veteran had a VA spine examination in December 1996. He reported two post-service low back injuries. He stated that in 1978 he fell off a truck, falling ten feet and landing on his buttock. He indicated that the 1978 injury was followed by numbness in both thighs. He stated that clinicians found that he had a herniated lumbar disc, and he underwent back surgery, with laminectomy and discectomy, in 1978. He related sustaining another back injury in 1990, when he tripped and pulled his back. He indicated that another herniated disc was found, and he had another back surgery in October 1990. At the time of the 1996 examination the Veteran reported intermittent low back pain, occasional shooting pain at both hips, and right foot drop. The examiner found that objective evidence of pain with motion of the lumbar spine was minimal. The examiner found right foot drop. The examiner's diagnosis regarding the Veteran's back was degenerative disc disease with a history of industrial injuries and spine surgery. In December 1997, the Veteran received VA treatment for mid scapular back pain. He reported that the pain began earlier the day of treatment, when a box struck his back in an accident at a store. In September 2007, the Veteran again requested VA compensation for back problems. He indicated that he had back injuries during service, possibly during training, and received treatment during service for those injuries. In February 2008, he wrote that he had back problems during service and continued to have back problems thereafter. He stated that he had his first back surgery in 1977. In May 2010, he wrote that he could not remember whether he was treated for back symptoms during service, but that he recalled having back problems during a period of inpatient psychiatric treatment during service. As there is no competent evidence that the Veteran had spine arthritis within a year following his separation from service, service connection for his current spine arthritis may not be presumed. The Veteran's service treatment records do not contain any reports of back injury, symptoms, or treatment. Post-service medical treatment records show that the Veteran had a back injury and surgery in 1978. Records from that time do not reflect any reports of prior back problems. From 1978 through 1997 the Veteran repeatedly indicated that his back symptoms began with the injury in 1978, almost fifteen years after service. Only with filing this current claim, has he stated that, during his service in 1962 and 1963, he sustained back injuries and had treatment for back symptoms. In fact, even when he filed his prior claim that his back condition was due to VA treatment, he did not allege he had ever incurred any back injuries during service. The medical records and Veteran's statements from the time of Veteran's service and soon thereafter are likely to reflect fairly accurate recollections regarding the condition of the Veteran's back during service. Moreover, for many decades while seeking treatment for his back, he reported onset long after service. On the question of whether the Veteran had back injury or symptoms during service, then, the more contemporaneous evidence is more credible than the Veteran's recent assertions. The Board finds his current assertions that he had back injuries or back pain during service are simply not credible and are contradicted by voluminous post-service treatment records. No medical professional has ever indicated the Veteran's back condition is possibly due to an in-service injury, and the Veteran's statements to this effect are not competent, as it would involve internal disease process, and not credible, as described above. The Board concludes that the greater persuasive weight of the evidence is against a service origin for the current back disability. Heart Disability The Veteran essentially contends that his current heart disability began during service, was caused or aggravated by medication prescribed during service, or is attributable to herbicide exposure during his service in Guam in the early 1960s. Cardiovascular renal disease, including hypertension, is among the chronic diseases for which service connection is presumed if the disease manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. Under certain circumstances, service connection for specific diseases may be presumed if a veteran was exposed during service to certain herbicides, including Agent Orange, that contain dioxin. 38 U.S.C.A. § 1116 (West 2002); 38 C.F.R. §§ 3.307, 3.309(e) (2013). If a veteran was exposed to Agent Orange or another herbicide agent, service connection for any of the conditions listed under 38 C.F.R. § 3.309(e), including ischemic heart disease, will be presumed if the condition becomes manifest to a degree of 10 percent disabling or more. A veteran who served on active duty in the Republic of Vietnam during the period from January 9, 1962 to May 7, 1975, 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 service. 38 C.F.R. § 3.307(a)(6)(iii). The Veteran did not serve in Vietnam, however. His service records show that he served in the continental United States and in Guam. He contends that he was exposed to herbicides during the five weeks he served in Guam in July and August 1963. The presumption of herbicide exposure based on Vietnam service does not apply in this case. The Board will consider the evidence regarding the Veteran's contention that he was exposed to herbicides in Guam. In a July 1962 medical examination of the Veteran for entrance into service, the examiner found no cardiovascular or chest abnormality. In August 1963, the Veteran was admitted to a service hospital due to an emotional or behavioral episode. He reported that he was taking Dexedrine or Dexamyl for diet control, and that on a particular night he took five pills of that medication to stay awake. When a clinician saw the Veteran the following day, the Veteran was agitated, irritable, and extremely jumpy. A psychiatrist concluded that the Veteran's emotional state on that initial consultation was related to the after effects of the Dexamyl. On an October 1963 examination for separation from service, the examiner found no cardiovascular or chest abnormality. The Veteran does not report that he had any heart treatment during the year following his separation from service, and the claims file does not contain any evidence regarding the condition of his heart during that year. The claims file contains records of post-service medical treatment of the Veteran by private and VA clinicians from the late 1970s forward. In February 1987, a VA clinician found that the Veteran had elevated blood pressure. From 1988 forward the Veteran received VA treatment for arteriosclerotic heart disease. He underwent cardiac catheterization in March 1988 and coronary artery bypass graft surgery in April 1988. He underwent additional cardiac catheterizations in August 1994 and January 2000. In September 2007, the Veteran stated that during service he was found to be overweight, and was given medications to control his weight. He asserted that those medications caused his current heart problems. In February 2008, the Veteran contended that weight control medication prescribed to him during service kept him awake, made him stressed, and may have caused his current heart problems. Later in 2008, the Veteran submitted an internet article regarding Dexamyl. Members of the Veteran's family submitted statements in 2008. One family member, T. B. M., wrote that in 1963 service clinicians prescribed the Veteran the diet control medication Dexamyl. Mr. M. stated that in 1963 the Veteran wrote to him that on Dexamyl he could not sleep and was tense and depressed. The Veteran's mother wrote that Dexamyl was prescribed to the Veteran during service for weight control, and that the Veteran had a reaction to the medication and had a breakdown. On VA medical examination in June 2008, the examining physician reported having reviewed the Veteran's claims file. The Veteran reported that during service he was put on Dexamyl, one pill a day, because he was overweight. He stated that he was on Dexamyl for over a year. The examiner noted the Veteran's treatment from the late 1980s forward for heart disease. The examiner found that the Veteran had coronary artery disease (CAD) with ischemic cardiomyopathy. The examiner provided an opinion regarding the claim that Dexamyl use in service led to the Veteran's heart disease, as follows: Dexamyl has possibly been linked with CAD. However, this occurs while the patient is using the medication. This veteran's CAD was not diagnosed until over 20 years after he used it. Therefore, his CAD and ischemic cardiomyopathy were not caused by his Dexamyl use. In May 2010, the Veteran wrote that Agent Orange was sprayed in Guam from 1955 to the 1960s. In the December 2012 remand, the Board instructed that the AMC or RO develop evidence regarding the Veteran's contention that he was exposed to herbicides containing dioxin during service in Guam. The AMC made an inquiry to DOD regarding the Veteran's claim that he was exposed to herbicides during his service in Guam in 1963. In July 2013, the Defense Personnel Records Information Retrieval System (DPRIS) reported having reviewed the 1963 command history for the U. S. Naval Station on Guam, and the DOD listing of herbicide spray areas and test sites outside of Vietnam. DPRIS stated, "There is no mention of Agent Orange, and other tactical herbicides, being used, tested, disposed of or stored on the island of Guam." The AMC issued a formal finding that DOD evidence failed to confirm or corroborate that the Veteran was exposed to herbicides during service. Medical records do not show that the Veteran had manifestations of heart disease during service. There is not competent medical evidence that the heart disease diagnosed in the 1980s manifested to a compensable degree within a year after the Veteran's 1963 separation from service. The Board therefore does not presume that the current heart disease was incurred in service. In post-service medical records from the late 1970s forward, the earliest diagnosis of heart disease is in the late 1980s. The VA physician who examined the Veteran in 2008 is competent to address the issue of the likely effect of medication use on the later development of disease. The Board finds persuasive that physician's well-explained opinion that the Veteran's Dexamyl use in service in the 1960s did not cause the heart disease diagnosed in the 1980s. There is no medical opinion to the contrary. The Veteran's assertions as to causation are simply not competent, since they involve internal disease processes. The preponderance of the evidence thus is against incurrence in service of the Veteran's current heart disease or development of heart disease as a result of Dexamyl use in service. Research into DOD records did not corroborate that tactical herbicides were used in Guam in or around 1963. The Board gives considerable credence to military records regarding where and when tactical herbicides were used. The Veteran has not provided any basis for his contention that tactical herbicides were used in Guam in the 1950s and 60s; he simply stated such herbicides where used, without giving any indication of personal knowledge of such use. The greater weight of the evidence thus is against the Veteran's contention that he was exposed to herbicides during service. Therefore his current heart disease may not be presumed service connected based on herbicide exposure. Hypertension The Veteran essentially contends that his current hypertension began during service, was caused or aggravated by medication prescribed during service, or is attributable to herbicide exposure during his service in Guam in the early 1960s. Cardiovascular renal disease, including hypertension, is among the chronic diseases for which service connection is presumed if the disease manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. Although ischemic heart disease is among the diseases for which service connection may be presumed in a veteran who was exposed to herbicides during service, the term ischemic heart disease does not include hypertension. 38 C.F.R. § 3.309(e) (Note 3). In addition, as noted above, the Board finds that the Veteran was not exposed to herbicides during his service. Therefore, the Board will not consider claimed herbicide exposure as a basis for service connection for the Veteran's hypertension. The Veteran's service entrance examination, treatment records, and separation examination do not show any elevated blood pressure readings nor findings of hypertension. There is no record of the Veteran's blood pressure during the year following his separation from service. In records of post-service medical treatment of the Veteran in the late 1970s forward, records from 1987 forward contain findings of elevated blood pressure and diagnoses of hypertension. The Veteran contends that Dexamyl prescribed in service caused or contributed to causing his hypertension. There is evidence that he was tense, irritable, agitated, and sleep-impaired while on Dexamyl. On VA examination in June 2008, the Veteran stated that he was diagnosed with hypertension in 1986 or 1987. He indicated that he was on medications for hypertension. With regard to the claim that Dexamyl use in service caused the Veteran's hypertension (HTN), the examiner provided an opinion, as follows: Dexamyl has typically not been associated with HTN. In addition, even if it were to have caused his HTN, he would have had HTN while on the medication and it would have resolved when he stopped it. In this veteran's case, he was not diagnosed with HTN until over 20 years later. For these reasons, his HTN was not caused by his use of Dexamyl in the military. Medical records do not show that the Veteran's hypertension manifested during service or the year following service. There is no indication that hypertension manifested earlier than the mid 1980s. The 2008 VA examiner provided and explained a persuasive opinion that the Veteran's Dexamyl use in service did not cause the hypertension that manifested long after service. There is no medical opinion to the contrary. The Veteran's assertions as to causation are simply not competent, since they involve internal disease processes. The Board finds that the preponderance of the evidence is against incurrence of hypertension in service or development of hypertension as a result of Dexamyl use is service. In addition, the history of the Veteran's hypertension does not warrant presumption of service connection. Diabetes Mellitus The Veteran essentially contends that his current type 2 diabetes mellitus began during service, was caused or aggravated by medication prescribed during service, or is attributable to herbicide exposure during his service in Guam in the early 1960s. Diabetes mellitus is among the chronic diseases for which service connection is presumed if the disease manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. In addition, type 2 diabetes mellitus is among the diseases for which service connection may be presumed in a veteran who was exposed to herbicides during service. 38 C.F.R. § 3.309(e). As the Board has found, however, that the Veteran was not exposed to herbicides during his service, the Board will not consider claimed herbicide exposure as a basis for service connection for the Veteran's diabetes. The Veteran's service entrance examination, treatment records, and separation examination do not show any findings of diabetes. The Veteran does not contend, and no medical records show, that diabetes was diagnosed during the year following his separation from service. The claims file contains records of post-service medical treatment of the Veteran in the late 1970s forward. In May 1996, a VA clinician diagnosed type 2 diabetes mellitus. That diagnosis continues to appear in subsequent medical records. The Veteran contends that Dexamyl prescribed in service caused or contributed to causing his diabetes. On VA examination in June 2008, the Veteran reported that his diabetes was diagnosed in the late 1980s, and that it was treated with oral medications. The examiner provided the opinion that the Veteran's diabetes was not caused by his Dexamyl use in the military. He explained that Dexamyl has not been associated with diabetes. There is no medical opinion to the contrary. The Veteran's assertions as to causation are simply not competent, since they involve internal disease processes. Considering the medical evidence that the Veteran's diabetes was not diagnosed until many years after service, and the competent medical opinion against an association between the use of Dexamyl in service and the current diabetes, the preponderance of the evidence is against service incurrence of diabetes, and against a connection between Dexamyl use in service and post-service diabetes. The history of the Veteran's diabetes does not warrant presumption of service incurrence. The Board therefore denies the service connection claim. ORDER Entitlement to service connection for back disability is denied. Entitlement to service connection for heart disability is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for type 2 diabetes mellitus is denied. ______________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs