Citation Nr: 1805248 Decision Date: 01/26/18 Archive Date: 02/07/18 DOCKET NO. 14-15 590 DATE THE ISSUE Entitlement to service connection for diabetes mellitus, type II. ORDER Service connection for diabetes mellitus, type II, is denied. FINDING OF FACT Diabetes mellitus, type II, did not manifest in service, is not related to service, and did not manifest within one year of service discharge. CONCLUSION OF LAW The criteria for service connection for diabetes mellitus, type II, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107(b) (2012); 38 C.F.R. § 3.102, 3.303, 3.307, 3.309(a) (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Introduction The Veteran served on active duty from July 1971 to May 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office in Houston, Texas (RO). This appeal was processed using the Virtual VA (VVA) and Veterans Benefits Management System (VBMS) paperless claims processing systems. Accordingly, any future review of this Veteran's case should take into consideration the existence of these electronic records. Veterans Claims Assistance Act of 2000 As required by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist veterans in substantiating claims for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159(b) (2017). The Veteran has not raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). As such, the Board will now review the merits of the Veteran's claim. Law and Analysis The Veteran has contended on his September 2011 notice of disagreement and his April 2014 VA Form 9, that he was diagnosed with diabetes mellitus, type II, while in service and that he continues to suffer from the disability. The Veteran does not claim nor does the evidence show service in the Republic of Vietnam. In general, service connection may be granted for a disability or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) an in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303(a) (2017). For certain enumerated chronic diseases, such as diabetes, service connection may be granted based upon a presumption of incurrence in or aggravation by service despite the lack of evidence of such disease during service if diagnosed and manifested to a compensable degree within a prescribed period, generally one year, after separation from qualifying service. 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a) (2017); see Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); see also Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013) (constraining § 3.303(b) to those chronic diseases listed in § 3.309(a)). Additionally, for those same enumerated chronic diseases service connection may be granted despite the lack of evidence of such disease during service if there is 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 a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b), 3.309(a) (2017); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. 38 C.F.R. § 3.307(b) (2017). In making determinations, VA is responsible for ascertaining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Here, the Board reviewed all evidence in the claims file, with an emphasis on that which is relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran's claim. With respect to the first Holton element, current disability, the Veteran's VA medical records show that in October 2010 it was recorded that the Veteran had been treated for diabetes mellitus type II since 2005. His records also show that in October 2015 he was prescribed to take 20 units insulin per day for the treatment of diabetes. Accordingly, first Holton element is met. With respect to the second Holton element, in-service incurrence or aggravation of a disease or injury, the Veteran claims that in March 1972 he was diagnosed as having diabetes. The Board finds, however, that the competent evidence of record shows that the Veteran did not have any symptoms, complaints, diagnosis, or treatment of diabetes while in service. The Veteran's service treatment records show that one morning in March 1972 the Veteran was brought to the dispensary on a stretcher after having reportedly collapsed in the barracks. It was recorded that he was unconscious and twitching. It was recorded that he was treated with intravenous fluids and after fifteen minutes he regained consciousness. The Veteran reported that he had been up the whole night drinking nearly a case of beer. The recorded impression was hyperventilation syndrome induced by excessive drinking. The Veteran's service treatment records show that he was treated again that night when he was admitted via litter, non-responsive to painful stimuli or verbal commands. It was noted that he had been seen that morning with a similar episode. It was noted that after the administration of oxygen, he became reactive. It was noted that the Veteran was very vague about history of just having stomach and chest pain. The noted impression was hyperventilation, rule out diabetes mellitus, and rule out cardio-respiratory disease. Additional notes were provided two hours later, recording that the Veteran was seen for abdominal pain, hyperventilation, fights than calm to semi-conscious. He was treated with 50 cc of 50 percent glucose, given intravenously. He was seen in a stuporous condition alternating with thrashing about. He was unable to respond to questions but during semi-lucid times he denied epilepsy, diabetes, and he complained of right lower quadrant abdominal pain. It was recorded that the Veteran's barrack-mates reported that he had been drinking beer that night and that he was seen to fall to the floor. It was noted that there was a history of previous fainting similar to this one week before. It was noted that there was also a history of an injury to the right groin several days before. The Veteran was noted to be generally disoriented; pupils equal and reactive to light; fundus oculi within normal limits. It was noted that when the Veteran was awake, there was a complaint of pain when palpating the right testicle and right groin. It was recorded that the Veteran's blood glucose was 60 mg percent and that there was no immediate result after the administration of a bolus of 50 cc 50 percent glucose. It was noted that the Veteran became oriented and not complaining of pain, and he was discharged to the barracks. A clinical record cover sheet for the General Medical Service shows that in March 1972 the Veteran was diagnosed as having experienced hyperventilation, cause undetermined, and syncope episodes secondary to the hyperventilation. The Veteran's service treatment records contain an entry that during a two-day period in March 1972 the Veteran had hyperventilation episodes that improved. The following week it was noted that he had been seen for possible hyperventilation syndrome and that he would need medical permission to jump. The Veteran's March 1973 separation examination does not contain any indication that the Veteran had been evaluated for diabetes, and the Veteran hand wrote on the report that he was in good health. In April 1973, just prior to the Veteran's separation from service, it was noted that he reported that he was prone to hyperventilation. The Board finds that the competent evidence of record establishes that in March 1972, while the Veteran was on active duty, he overindulged in alcohol such that he had several episodes of hyperventilation syndrome. At the time he was treated for hyperventilation, the Veteran denied having a history of diabetes. Diabetes was listed in the Veteran's service treatment records on one occasion as a possible diagnosis to be ruled out, which it was since there is no record that the Veteran had any treatment-be it diet restriction or medication-for diabetes. Accordingly, the second Holton element is not met, and the claim for direct service connection fails. With respect to the third Holton element, medical nexus, the Board must consider whether there can be service connection for a chronic disease based upon presumption through evidence of continuity of symptomatology. The Board notes that the Veteran was diagnosed with diabetes in 2005, which was more than one year after he separated from service. The Board also notes that the Veteran's service treatment records are silent for any symptoms that could be identified as being those of diabetes regardless of the fact that diabetes was not diagnosed during service. The Board finds the Veteran competent to report his symptoms of diabetes. 38 C.F.R. § 3.159(a)(2) (2017); see Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (noting that lay evidence is competent with regard to facts perceived through the use of the five senses). On the other hand, generally speaking, "lay persons are not competent to opine on medical etiology or render medical opinions." Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Here, the Veteran has not stated the nature of the symptoms that led to the diagnosis of his diabetes in 2005, and he has not stated how and when he experienced those same symptoms while in service and thereafter. The evidence of record is silent for any symptoms of diabetes prior to the Veteran's diagnosis in 2005. The claimant bears the burden of presenting and supporting a claim for benefits. 38 U.S.C. § 5107(a) (2012); Fagan v. Shinseki, 573 F.3d 1282, 1286-88 (Fed. Cir. 2009). In the absence of evidence of continuity of symptomatology of diabetes during and after service, a medical nexus opinion would seem to be an impossibility. Accordingly, the third Holton element is not met, and the claim fails on a presumptive basis as well. In an April 2016 statement, the Veteran's representative asserted that while in service the Veteran was diagnosed with hepatitis in September 1972 and argued that there is a known direct link between hepatitis C and diabetes such that the Veteran's diabetes should be service connected secondary to his hepatitis. In a September 2014 rating decision, the RO denied service connection for hepatitis because, although it could have been due to the Veteran's substance abuse during service, it is not subject to service connection because it is not considered in the line of duty and is due to willful misconduct. This decision was continued in a June 2015 statement of the case. The Veteran did not perfect his appeal of this issue and, therefore, there is no basis for considering whether the Veteran's diabetes is etiologically related to his hepatitis. Based upon the foregoing, as the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply, and the claim must be denied. See 38 U.S.C. §§ 501, 5107(b) (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7 (2017); see also Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). ______________________________________________ LANA K. JENG Veterans Law Judge, Board of Veterans' Appeals ATTORNEY FOR THE BOARD Leanne M. Innet, Associate Counsel Copy mailed to: Disabled American Veterans Department of Veterans Affairs