Citation Nr: 1549865 Decision Date: 11/25/15 Archive Date: 12/03/15 DOCKET NO. 09-23 689 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for type II diabetes mellitus. REPRESENTATION Appellant represented by: George C. Piemonte, Attorney WITNESSES AT HEARING ON APPEAL The Veteran, E.L., and R.H. ATTORNEY FOR THE BOARD M. Postek, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1978 to October 1989. This case comes before the Board of Veterans' Appeals (Board) on appeal from an April 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Jurisdiction over the case was subsequently transferred to the RO in Winston-Salem, North Carolina. A hearing was held before a Decision Review Officer (DRO) at the RO in March 2009. A videoconference hearing was held before the undersigned Veterans Law Judge in June 2011. Transcripts of both hearings are of record. The Board most recently remanded the case for further development in February 2015. Thereafter, the Board requested an advisory medical opinion from the Veterans Health Administration (VHA) in November 2015. Because the Board is granting the benefit sought on appeal in full, there is no prejudice to the Veteran in proceeding with adjudication of the claim at this time, i.e., without first sending a copy of the opinion to the Veteran and his representative to allow them a 60-day period to submit responsive evidence or argument. See 38 C.F.R. §§ 20.901, 20.903 (2015). This appeal was processed using the Veterans Benefits Management System (VBMS). The Virtual VA electronic claims file contains documents that are either duplicative or irrelevant to the issue on appeal, with the exception of additional VA treatment records that were already considered by the RO. FINDING OF FACT The Veteran has current type II diabetes mellitus that had its onset during service. CONCLUSION OF LAW Type II diabetes mellitus was incurred in active service. 38 U.S.C.A. § 1131 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran has contended that his diabetes mellitus is related to his military service. Specifically, he alleges that, although he was not diagnosed with diabetes mellitus until shortly after service, his symptoms began therein. Throughout the course of this appeal, he has reported having in-service symptoms, including constant thirst, weight gain, and frequent urination. He indicated that he did not seek treatment out of concern that he would be "kick[ed] out" of the military. See, e.g., March 2009 Decision Review Officer (DRO) Hrg. Tr. at 2. He also recalled having a glucose test at his final physical with a reported level of 312; he reported that he was told this laboratory finding was missing from his service treatment records. See DRO Hrg. Tr. at 5, 13. The Veteran's service treatment records do not document any complaints, treatment, or diagnosis of diabetes mellitus or indicative symptoms, such as increased thirst or increased urinary frequency. During the Veteran's examinations at entrance (January 1978), reenlistment (March 1985), and separation (August 1989), his endocrine and genitourinary systems were found to be normal. In each instance, urinalysis testing revealed negative results for albumin and sugar, and laboratory testing slips from February 1985 (reenlistment) and August 1989 (separation) show that his urine chemistry was negative for glucose. See also October 1989 physical status statement at separation (normal PULHES profile). In regard to some of the Veteran's claimed in-service symptomatology, the Veteran reported having recent weight gain or loss in reports of medical history on examinations at entrance (January 1978), reenlistment (March 1985), and separation (August 1989). In February 1989, he was referred to the nutrition clinic to begin a weight reduction program. A report of frequent or painful urination on the reenlistment examination was noted to be related to a urinary tract infection. See also November 1984 triage note (complaint of recent painful urination and report of injury from sexual activity; assessment of penile abrasion). The Veteran also complained of a sore throat approximately one week prior to the separation examination; an assessment of tonsillitis was made at that time. See August 9, 1989 service treatment record; August 1989 report of medical history. See also May 1983 health history report, December 1984 health history report, and September 1988 dental treatment health history report (additional in-service reported symptoms). The post-service medical evidence shows that the Veteran began receiving treatment for diabetes mellitus in 1991. In addition, laboratory testing conducted in 1992 and 1993 showed high glucose levels. The post-service medical evidence also shows that the Veteran has developed complications related to his diabetes mellitus. See, e.g., July 2000 Dr. M.B. private treatment record (impression including persistent proliferative diabetic retinopathy in both eyes); July 2009 Dr. W.B. private treatment record (diagnoses including end stage renal disease secondary to diabetic nephropathy; chronic blindness secondary to diabetic retinopathy) (contained in Social Security Administration records in July 2014 VBMS entry); VA treatment records beginning in August 2000. In this case, the continued diagnosis in the VA and private treatment records satisfies the current disability requirement. Thus, the dispositive issue is whether there is a relationship between the Veteran's current type II diabetes mellitus and military service. There are multiple medical opinions that address the pertinent medical questions in this case. A written submission from Dr. W.R.N. dated in October 2007 (November 2007 VBMS entry) indicates that he initially treated the Veteran in January 1991, diagnosing him with uncontrolled diabetes. Dr. W.R.N. stated that the Veteran had long-standing diabetes at that point, as evidenced by the development of diabetic cataracts around that time. He based this opinion, in part, on an understanding that the military had lost all of the Veteran's laboratory results; he indicated that, had there been even one in-service urinalysis, it would have shown glucose in the Veteran's urine. A written submission from Dr. W.B. dated in October 2007 (November 2007 VBMS entry) indicates that he diagnosed the Veteran with type II diabetes mellitus at that time and that the Veteran probably had the disease prior to 1989 based on his symptoms. Another written submission from Dr. W.B. dated in November 2007 (March 2009 VBMS entry) shows that the Veteran continued to undergo treatment for his diabetes mellitus, including related end-stage renal disease due to diabetic nephropathy and blindness. He noted the Veteran's reports of intermittent symptoms of fatigue, frequent urination, and thirst in service, which he indicated were symptoms consistent with the diagnosis of diabetes mellitus. He also commented that the diagnosis may have been elusive depending on many factors when the laboratory results were checked. He further stated that it may be difficult to know exactly when the Veteran developed diabetes mellitus, but generally, it takes about 10 to 20 years for the disease to result in end organ dysfunction resulting in blindness and renal failure. Based on the complications noted above, he suspected that the Veteran had diabetes mellitus for 15 to 20 years earlier. In a written submission from Dr. W.B. dated in May 2011 (June 2011 VBMS entry), he indicated that it was possible that the Veteran's diabetes mellitus could be a function of his toxin exposure in the military. Dr. W.B. noted that he was not in possession of the Veteran's military medical records, but stated that mildly elevated glucose levels in the 1980s and possibly 1990s may not have been accepted as evidence for diabetes mellitus based on the medical standards at that time. The Board acknowledges the medical opinions submitted by the Veteran's private physicians; however, these opinions are inadequate inasmuch as it appears that the physicians did not address the fact that there were negative laboratory findings in the Veteran's service treatment records. Dr. W.R.N.'s opinion is based, in part, on the rationale that, had there been one in-service urinalysis, it would have shown glucose in the Veteran's urine. Dr. W.B.'s opinion is based, in part, on the Veteran's "toxin exposure" during service. Such is not shown by the record or further explained by the physician. An October 2014 VA examiner determined that it was less likely as not that the Veteran's diabetes mellitus manifested in service or within one year thereafter or was otherwise related to his active duty service. In so finding, the examiner noted that the urinalysis testing at the time of the separation examination yielded normal results and that there was no diagnosis of diabetes mellitus during service. She acknowledged Dr. W.R.N.'s statement regarding "diabetic cataracts" as evidence of the Veteran's longstanding diabetes mellitus; however, she explained that medical evidence does not support the indication that diabetes causes cataracts. Therefore, she stated that the presence of cataracts is not an indicator of how long a patient may or may not have had diabetes. In a May 2015 clarifying opinion, the VA examiner again determined that it was less likely as not that the Veteran's diabetes mellitus manifested in service or within one year thereafter or was otherwise related to his active duty service. In so finding, the examiner provided the rationale from her previous opinion. She also noted that Dr. W.B.'s statement as to the in-service onset of the disease was speculative. In addition, she explained that diabetes mellitus is diagnosed by objective criteria and noted that there were no documented objective findings of diabetes mellitus found during active duty or within close proximity thereto. While the VA examiner addressed some of the remaining questions on the possible etiology of the Veteran's diabetes mellitus, these opinions are inadequate because it is unclear if the examiner considered the complete history of the development of the Veteran's diabetes mellitus, including his reported history of symptoms, the post-service laboratory testing, and the development of any related complications, in providing the opinion. The November 2015 VHA physician determined that it was at least as likely as not that the Veteran's diabetes mellitus manifested in service based on the rapid development of his severe complications soon after discharge. In so finding, the physician explained how the development of the Veteran's diabetes and its related complications in this case, including the documented marked hyperglycemia within two years of discharge, followed soon after by complications including cataracts (for which diabetes is actually a medically recognized risk factor), retinopathy, and, eventually, diabetic nephropathy and end-stage renal disease, supported this conclusion based on accepted medical knowledge of the expected course of diabetes and its complications. He also indicated that diabetic complications can develop very rapidly in type I ("childhood") diabetes, but noted that that the development of vascular complications in type II ("adult onset") diabetes occurs over years to decades. In other words, even when severely increased albuminuria was present, it took a median duration of a decade until renal replacement therapy (dialysis or renal transplantation) was needed based on cited published findings. The Board finds that this opinion indicating that the Veteran's diabetes mellitus had its onset during his military service is significantly probative, as it is based on a review of the claims file, and it is supported by rationale. This is the one medical opinion that considers the complete factual history. Thus, the Board concludes that service connection for diabetes mellitus is warranted. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. ORDER Entitlement to service connection for type II diabetes mellitus is granted. ____________________________________________ J.W. ZISSIMOS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs