Citation Nr: 18139568 Decision Date: 10/01/18 Archive Date: 09/28/18 DOCKET NO. 06-26 725 DATE: October 1, 2018 ORDER Entitlement to service connection for pancreatic disability (claimed as hemorrhagic pancreatitis, status post-total pancreatectomy), to include as due to herbicide exposure, is denied. Entitlement to service connection for diabetes mellitus type 2, to include as due to herbicide exposure, is denied. FINDINGS OF FACT 1. The Veteran’s pancreatic disability (claimed as hemorrhagic pancreatitis, status post-total pancreatectomy) is not etiologically related to an in-service injury, event, or disease, to include herbicide exposure. 2. The Veteran’s diabetes mellitus type II is not etiologically related to an in-service injury, event, or disease, and has been shown to have been attributed to an intervening cause of nonservice-connected hemorrhagic pancreatitis. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a pancreatic disability have not been met. 38 U.S.C. §§ 1110, 1113, 5100, 5102, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(b) (2017). 2. The criteria for entitlement to service connection for diabetes mellitus have not been met. 38 U.S.C. §§ 1110, 1113, 5100, 5102, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307(a), 3.309(e) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service in the Army from April 1968 until March 1970, including in the Republic of Vietnam from April 4, 1969 through March 23, 1970. These matters come before the Board of Veterans’ Appeals (Board) on appeal of March 2006 and January 2015 rating decisions by the Department of Veterans Affairs (VA) Regional Offices (RO) in Detroit, Michigan, and Newman, Georgia, respectively. Jurisdiction currently resides with the RO in Detroit, Michigan. The Veteran appeared before the undersigned Veteran’s Law Judge during a video conference hearing in October 2015. A transcript of the hearing is associated with the claims file. The Board previously remanded these matters for further development in June 2009, January 2011, March 2016, and July 2017. For the reasons discussed in the following section, the Board finds that VA has substantially complied with remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D’Aries v. Peake, 22 Vet. App. 97 (2008); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Duty to Notify and Assist Pursuant to the Veterans Claims Assistance Act of 2000 (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, and 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2017). 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/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran was provided with VCAA notice for his claims in October 2005 and March 2013, and acknowledged receiving the same in December 2005 and April 2013, respectively. 38 U.S.C. § 5103. Thus, VA has met the duty to notify. In July 2017, the Board remanded the appeal for an additional VA examination to determine whether the Veteran’s diagnosed hemorrhagic pancreatitis and/or diabetes mellitus are etiologically related to his military service, to include presumed exposure to herbicides in Vietnam. The Veteran was provided with a VA examination in August 2017, and the examiner provided etiology opinions for the requested disabilities. The Veteran’s representative argued in an August 2018 informal hearing presentation (IHP) that the examination failed to comply with the remand directives because the examiner did not discuss any medical association between “herbicides, [diabetes mellitus] and hemorrhagic pancreatitis,” did not do additional testing, and relied on an inadequate rationale. However, the plain language of the remand order does not require the examiner to discuss medical associations between herbicides, diabetes, and pancreatitis, or conduct additional testing unless it is indicated. See BVA Remand, July 2017. The VA examiner provided a medical opinion with supporting rationale, as requested; therefore, VA has substantially complied with the remand directives. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); D’Aries v. Peake, 22 Vet. App. 97 (2008); Stegall, 11 Vet. App. at 271. The Veteran and his representative have requested an independent medical opinion. See 38 C.F.R. § 20.902. However, such a request will only be granted upon a showing of good cause, such as the identification of a complex or controversial medical or legal issue involved in the appeal. Id. For the reasons explained in subsequent analysis, the Board finds that there is not good cause shown for an independent medical opinion because the probative medical evidence of record is not in controversy over the etiology of the Veteran’s disabilities. The Veteran’s representative requested a legal opinion from VA’s Office of General Counsel relating to constitutional concerns about “equal protection” relating to Agent Orange claims. See U.S. Const. amend. V; 38 C.F.R. § 20.901 (c). He argued that present treatment of presumption of exposure to Agent Orange is patently arbitrary and irrational, resulting in the granting of claims to Veterans with little to no likelihood of exposure to Agent Orange. He referenced the claim of another Veteran, for whom service connection was granted with the only proof of Agent Orange exposure being a ticket voucher showing 20 minutes spent on the ground in Vietnam while changing planes, while the Veteran in the instant claim was a combat infantryman with a year of service in Vietnam. Every claim before VA will necessarily involve different facts and circumstances, and VA regulations state that previously issued Board decisions will be considered binding only with regard to the specific case decided. 38 C.F.R. § 20.1303. Although it may sometimes appear that disparate outcomes occur in herbicide presumption cases, this does not demonstrate that a particular Veteran is unfairly singled out for unequal treatment. See, e.g., Reeves v. West, 11 Vet. App. 255, 259 (1998) (a party challenging a law on equal protection grounds has the burden of showing that the totality of the relevant facts gives rise to an inference of discriminatory purpose). The Board finds that there is not good cause shown to procure a legal opinion. See 38 C.F.R. § 20.902. The Veteran was provided with several VA examinations over the course of his appeal. Furthermore, he has not alleged that there are any outstanding records relevant to his claim that have not been associated with the claims file. 38 U.S.C. § 5103A. Therefore, VA has met the duty to assist. Service Connection To establish service connection for a disability on a direct-incurrent basis, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also 38 C.F.R. § 3.303. A disability which is proximately due to or the result of a service-connected disease or injury shall be service-connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will also be service-connected. 38 C.F.R. § 3.310 (b). Entitlement to service connection for pancreatic disability, including as due to herbicide exposure The Veteran seeks entitlement to service connection for a pancreatic disability, claimed as pancreatitis, post-total pancreatectomy, including as due to herbicide exposure. As a preliminary matter, the Veteran’s service personnel records demonstrate that he served in Vietnam as a rifleman from April 1969 until March 1970. The Veteran’s Form DD-214 shows that he was issued the Vietnam Service Medal, the Vietnam Campaign Medal, the Combat Infantry Badge, and the Bronze Star, among other honors. Considering the foregoing, exposure to Agent Orange is conceded. The Veteran had hemorrhagic pancreatitis and necrotic pancreas debridement in April 2000. In August 2017, a VA examiner confirmed the occurrence of a total pancreatectomy in April 2000. Therefore, the Veteran has a current disability. The Veteran’s service treatment records do not evince any complaints, treatment, symptoms, or findings of pancreatic conditions. Pancreatitis, or hemorrhagic pancreatitis, is not listed among the conditions presumptively related to Agent Orange exposure under 38 C.F.R. § 3.309. However, the Board will nevertheless consider whether the Veteran’s pancreatitis is related to his military service on a direct-incurrence basis, including as due to exposure to Agent Orange. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); McCartt v. West, 12 Vet. App. 164, 167 (1999). The procedural history of the Veteran’s claim for entitlement to service connection for pancreatitis substantially overlaps with his claim for service connection for diabetes mellitus. The Veteran filed an informal claim for compensation and pension in August 2005, and submitted a formal claim in September 2005. He requested compensation for diabetes mellitus type 2 on a presumptive basis due to Agent Orange exposure. The Veteran submitted a letter from a private physician, Dr. J.F., in October 2005. Dr. J.F. stated that he knew the Veteran when he was admitted to the hospital for acute pancreatitis and multiple complications in April 2000. Dr. J.F. indicated that the Veteran had hyperglycemia on that occasion, but denied any prior history of hyperglycemia, and has current a diagnosis of diabetes mellitus type 2. In November 2005, the Veteran submitted private medical records from his hospitalization for hemorrhagic pancreatitis. The records indicate that the Veteran had hemorrhagic pancreatitis, respiratory failure, and renal failure, and thereafter had several surgeries, including a debridement of necrotic pancreas. The records did not contain any etiology opinion for the hemorrhagic pancreatitis. The Veteran had a VA examination for diabetes mellitus, and a general pension medical examination, in January 2006. The VA examiner reviewed available medical records and conducted an in-person examination of the Veteran. The examiner indicated that the Veteran had diabetes mellitus type 2, and that its etiology was a result of the Veteran’s pancreatic surgery. However, she did not provide an opinion on whether the Veteran’s pancreatitis was due to his military service. In April 2006, VA received another letter from Dr. J.F. (dated September 2005). Dr. J.F. indicated that he saw the Veteran for the first time when he was asked to consult for acute renal failure that eventually required dialysis. He stated that there was no documented history of hyperglycemia or diabetes prior to the Veteran’s hospitalization; however, at that occasion, the Veteran did have severe hyperglycemia, which Dr. J.F. opined was probably related to the hemorrhagic pancreatitis. Dr. J.F. made the following statement regarding Agent Orange exposure as a causal factor for the Veteran’s disability: “I cannot establish the connection between the agent orange exposure to the above indicated problems. To mention, however, that the etiology of his pancreatitis was never determined, with all the common and unusual causes explored, and all of them being negative.” The Veteran submitted a February 1992 letter from Dr. J.S., which was written as a comment on a proposed VA rule regarding Agent Orange claims for Vietnam Veterans. Dr. J.S. opined that, on a medical basis, VA’s proposed rules were faulty and based upon unscientific ideas. She stated that diabetes should not be an exclusion, and that review of studies showed an increased incidence of diabetes among Vietnam Veterans. She wrote “the mechanism is unclear, as to whether Agent Orange components cause direct damage to the pancreas, or by some other indirect mechanism.” There is no indication that Dr. J.S. ever communicated with or examined the Veteran, or that she provided an etiology opinion specific to the Veteran’s disabilities. The Veteran had a VA examination for PTSD in October 2007. The Veteran reported a history of alcohol abuse beginning during his service in Vietnam. He indicated that he suffered from PTSD symptoms and “covered it up by drinking too much.” The Veteran reported having nightmares and insomnia, and that he began drinking heavily and using marijuana and Darvon tablets while in Vietnam. Upon discharge from service, he reported drinking heavily, becoming “alcoholic,” being cited once for drinking and driving, but denied further drug use. The Veteran reported drinking socially after his pancreatic operation. The Veteran’s representative later submitted statement indicating that “the pancreatitis we believe developed from the alcohol abuse which in turn was being used to self-medicate from the effects of his service connected PTSD…” In March 2009, the Veteran submitted lay statements indicating that basic probability suggested that his disability was due to Agent Orange exposure. He stated the probability of his exposure to Agent Orange was 100 percent, and the probability of Agent Orange damaging his pancreas, while not 100 percent, is certainly more than 50 percent. The Veteran had a VA examination for pancreatitis in October 2009. The VA examiner, Dr. B.N., reviewed the claims file, and conducted a physical examination with relevant laboratory testing. The veteran denied a history of pancreatic trauma, pancreatic neoplasm, or episodes of hypoglycemia or ketoacidosis. Dr. B.N. indicated that the “etiology of hemorrhagic pancreatitis is most probable [sic] a result of alcohol abuse. Medical records evidence alcohol abuse.” In November 2010, the Veteran submitted statements in support of his claim. He included a letter from his wife, who expressed offense that the Veteran had been accused of alcohol abuse. She stated that the Veteran had no medical documentation of such a diagnosis, and that his employment records did not evince any hint of alcohol abuse. She indicated that she was a registered nurse, and that there was never an issue with alcohol abuse during her marriage to the Veteran. The Veteran submitted a VA 21-4138, Statement in Support of Claim, in which he indicated that VA was getting “sidetracked” on the issue of alcohol abuse. He challenged VA to produce medical records of alcohol abuse, and stated that he had never been admitted to a detox facility, received treatment for alcohol abuse or any linked health issues, or been charged or convicted of DUI or any other alcohol related issues. He expressed disagreement with Dr. B.N., and claimed that her opinions contradicted Dr. J.F.’s findings ruling out all the common and unusual causes of pancreatitis. He submitted a statement dated September 2009, in which he encouraged VA to not become distracted by the alcohol abuse, and indicated that his “last significant alcohol abuse was in 1985, fifteen years before [his] hemorrhagic pancreatitis.” In January 2011, the Board remanded the appeal after finding that the RO had not specifically adjudicated the Veteran’s claim for service connection for alcohol abuse as secondary to PTSD and hemorrhagic pancreatitis as a result of exposure to herbicides like Agent Orange as required by its previous remand order. See BVA Remand, January 2011. Thereafter, the Veteran submitted a February 2011 statement withdrawing all arguments concerning alcohol abuse/alcoholism as a disability secondary to PTSD. He stated that he had provided a statement from his wife demonstrating that he does not have, and never had a problem with alcohol abuse/alcoholism. He further indicated that he conceded that VA correctly stated that his diabetes is secondary to having his pancreas removed, but that VA erred in determining the etiology of his hemorrhagic pancreatitis, and cited again to the letter from Dr. J.F., which purported to rule out all common and unusual causes for pancreatitis. In March 2011, Dr. B.N. was asked to provide an addendum opinion regarding whether the Veteran’s pancreatitis was an intercurrent cause of the Veteran’s diabetes. She reviewed the Veteran’s claims file, service treatment records, private medical records, and pertinent medical literature. She stated that there was no evidence of pancreatitis during service, and that medical literature substantiates the nexus of hemorrhagic pancreatitis to the development of diabetes. She listed common causes of pancreatitis, and noted that alcohol was the third most common on the list, and that in Western countries, chronic alcoholism and gallstones account for 85 percent of all cases of pancreatitis. Dr. B.N. noted that medical evidence of record contradicted lay statements from the Veteran and his wife denying alcohol abuse. She cited VA mental health notes from October 2009 and August 2009 in which the Veteran reported, respectively, drinking 6-8 beers three or more times a week after joining an Elks Lodge four years ago, and having an argument with his wife after drinking. Dr. B.N. opined that the above referenced facts established a nexus above substantial doubt between a long-documented history of alcohol consumption and the development of hemorrhagic pancreatitis. The Veteran submitted further lay statements in April 2013. He opined that his diabetes mellitus is the result of hemorrhagic pancreatitis, which was at least as likely as not caused by Agent Orange exposure in Vietnam. The Veteran indicated that there was reasonable doubt that should be resolved in his favor. In December 2014, the Veteran submitted medical research evidence to support his claim. He included abstracts from two articles, the first indicating that “pancreatic beta cells should be considered a relevant and sensitive target for dioxin acute toxicity,” and the second indicated that “chronic pancreatitis is a progressive inflammatory disease characterized by irreversible destruction of pancreatic secretory parenchyma, fibrosis, exocrine atrophy, and endocrine insufficiency leading to diabetes.” He also submitted an excerpt from an article which indicated, among other things, that “a lack of data in support of a plausible biologic mechanism [for Agent Orange exposure health outcomes] does not rule out the possibility that a causal relationship does exist.” He submitted further lay statements reiterating that Agent Orange exposure caused his pancreatitis and that reasonable doubt should be resolved in his favor. In December 2014, the Veteran had an additional VA examination with Dr. B.N. Dr. B.N. was asked to opine as to whether it was at least as likely as not that the Veteran’s pancreatitis was due to or the result of diabetes mellitus type 2. She reviewed the claims file, and conducted an in-person examination. She noted that the Veteran denied using alcohol, and that he wished to state that he was aware of the information in the record that he had issues with alcoholism, but that he never had such a problem. After completing relevant testing, Dr. B.N. opined that the Veteran’s pancreatitis was not proximately due to or the result of diabetes mellitus type 2. She reasoned that the Veteran did not have diabetes symptoms until after he underwent his pancreatectomy secondary to hemorrhagic pancreatitis. She further opined that VA medical records substantiated the fact that diabetes is secondary to the pancreatectomy because the pancreas produces insulin, and that there was no medical nexus substantiating that diabetes resulted in pancreatitis. The Veteran, his wife, and representative, appeared at a Board hearing in October 2015. The Veteran testified, among other things, that he was in sound condition before deploying to Vietnam, and immediately after his return. He explained that he did not have diabetes before having pancreatic symptoms, and that he believed his pancreatic condition was caused by Agent Orange due to the severity of the disability, and that Dr. J.F. had ruled out other causes. The Veteran’s wife testified, among other things, that she had been a registered nurse for 20 years, and that she had seen type 2 diabetes manifest in a multitude of ways. She discussed the history of the Veteran’s hospitalization for hemorrhagic pancreatitis, and described the impacts that the Veteran’s disability had on his daily life. The Veteran had an additional VA examination with Dr. B.N. in August 2017. She reviewed the claims file, examined the Veteran, and discussed the history of the present illness. She indicated that Veteran became diabetic when his pancreas was removed, and that he did not report any problems with his pancreas until 30 years after military service. Dr. B.N. stated that the Veteran’s diabetes mellitus is less likely as not incurred in or caused by service. She cited the Veteran’s private hospitalization and VA medicals records, and indicated that such evidence substantiated the fact that his diabetes is secondary to the pancreatectomy. Her rationale included that the Veteran’s hemorrhagic pancreatitis is not a presumptive diagnosis of Agent Orange, and the fact that the disability manifested 30 years after his discharge from the military. After careful consideration of the evidence of record, the Board finds that it is less likely than not that the Veteran’s pancreatic disability is proximately due to, or a result of, his military service, to include Agent Orange exposure. The Board may favor one medical opinion over another if it provides an adequate statement of reasons or bases. D’Aries v. Peake, 22 Vet. App. 97, 107 (2008). When determining how much probative weight to assign an opinion, the Board may consider the opining physician’s expertise and training, the facts and data on which the opinion is based, and the quality of the rationale supporting the opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301-02 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board has throroughly reviewed Dr J.F.’s medical opinion. Dr. J.F. stated: “I cannot establish the connection between the agent orange exposure to the above indicated problems. To mention, however, that the etiology of his pancreatitis was never determined, with all the common and unusual causes explored, and all of them being negative.” The first line of the opinion suggests that Dr. J.F. cannot opine as to the existence of a connection between Agent Orange and the Veteran’s disability. The Veteran argues that the second line of Dr. J.F.’s opinion indicates that all other causes for his pancreatic disability were eliminated, and that the only viable option is to invoke benefit of the doubt, and infer that Dr. J.F. meant to suggest his disability was a result of Agent Orange. The Veteran’s interpretation reflects a misunderstanding of the principles related to benefit of the doubt. Any right to the benefit of the doubt can only accrue when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 59 (1990). At no point did Dr. J.F. provide any positive evidence of a nexus, or indicate that Agent Orange caused or contributed to the Veteran’s condition. The second line of Dr. J.F.’s opinion merely suggests that the cause of the Veteran’s pancreatitis was not ascertained at the time of the opinion. Because Dr. J.F. did not provide an etiology opinion, or any positive evidence suggesting that the Veteran’s pancreatitis was due to Agent Orange exposure, the Board affords his opinion less probative weight. See Hood v. Shinseki, 23 Vet. App. 295, 298-99 (2009) (a medical examiner’s use of ambivalent or noncommittal phrases signals a speculative medical opinion of little probative value). Dr. B.N. examined the Veteran several times over the course of his appeal. In October 2009, she indicated that the Veteran’s hemorrhagic pancreatitis was due to alcoholism, and that his medical records evince alcohol abuse. In an addendum opinion in March 2011, Dr. B.N. cited specific examples of alcohol abuse reported by the Veteran and explained that alcohol abuse is a common cause of pancreatitis. She reasoned that the evidence establishes a nexus above substantial doubt, mere speculation, and remote possibility between a long-documented history of alcohol consumption and the development of hemorrhagic pancreatitis. Because Dr. B.N.’s opinion provided a thorough supporting rationale based on medical evidence of record, the Board affords her opinion high probative weight. D’Aries, 22 Vet. App. at 107; see also Prejean v. West, 13 Vet. App. 444 (2000). Dr. B.N.’s opinions in December 2014 and August 2017 also concluded that the Veteran’s disabilities were not related to service. In December 2014, Dr. B.N. stated that the Veteran’s pancreatitis was not due to or the result of diabetes, based on medical records confirming that he did not have diabetes until after his pancreas was removed. In August 2017, Dr. B.N. opined that diabetes and pancreatitis were not connected to the Veteran’s military service. She reiterated that the Veteran’s diabetes was a result of the pancreatectomy, and she opined that pancreatitis was not connected to service because it was not a presumptive diagnosis of Agent Orange, and did not manifest until 30 years after exposure. While Dr. B.N. did not mention alcohol abuse as a cause of pancreatitis in her August 2017 opinion, the Board notes that her findings are not inconsistent with her earlier opinions. Specifically, she did not attribute the pancreatitis to any cause in August 2017, but merely explained why it was not related to service. Because these opinions contain persuasive rationale supported by medical evidence, the Board affords them high probative weight. D’Aries, 22 Vet. App. at 107. The Board considered the article written by Dr. J.S. However, since there is no indication that Dr. J.S. ever examined the Veteran, or provided an opinion specific to his disability, such evidence is entitled to low probative weight. See Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). The Board has considered lay statements from the Veteran and his wife, and arguments from his representative. The Veteran is competent to testify as to the pancreatic symptoms he experiences, as such are within the capacity of a lay person to observe and report. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, he has not been shown to be competent to provide an etiology opinion on the cause of hemorrhagic pancreatitis, because such a determination requires complex medical knowledge of the interaction between multiple organ systems in the body, which he has not been shown to possess. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Veteran’s wife, as a registered nurse, has some medical knowledge; however, there are factors that weigh against her credibility. She stated that the Veteran has never had a problem with alcohol abuse, but this directly conflicts with the Veteran’s own reports, including history provided at the 2007 PTSD VA examination. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995). Considering the foregoing, the Board does not find her statements credible. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) (having an interest in the outcome of a proceeding may affect the credibility of lay testimony). In sum, the preponderance of the evidence is against finding that the Veteran’s pancreatic disability is due to, or a result of, any in-service injury, disease, or event, to include herbicide exposure. The benefit of the doubt does not apply, and the claim is denied. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). Entitlement to service connection for diabetes mellitus type 2. The Veteran seeks entitlement to service connection for diabetes mellitus type 2. Diabetes mellitus type 2 is among the conditions for which service connection can be granted based on presumed herbicide exposure, if manifest to a degree of 10 percent or more disabling at any time after service. See 38 C.F.R. §§ 3.307 (a)(6)(ii), 3.309 (e). However, the presumption may be rebutted by affirmative evidence to the contrary, including evidence of an intercurrent disease or injury. See 38 U.S.C. § 1113; 38 C.F.R. § 3.307 (d)(2). Service connection may also be established on a nonpresumptive direct-incurrence basis. See Combee, 34 F.3d at 1039. Probative medical evidence has directly attributed the Veteran’s diabetes to his pancreatitis, which is not a service-connected disability. For example, Dr. B.N. opined in August 2017 that the Veteran’s diabetes was caused by the pancreatectomy, and that hemorrhagic pancreatitis was less likely than not due to military service. She indicated that there was no evidence of diabetic symptoms until after the Veteran’s hemorrhagic pancreatitis, and that diabetes was due to the pancreatectomy because the pancreas produces insulin. In February 2011, the Veteran indicated that he thought VA was correct in attributing his diabetes to his pancreatectomy. However, he contended that his hemorrhagic pancreatitis was caused by Agent Orange exposure. Considering the forgoing, the Board finds that the probative evidence is not in dispute that the Veteran’s diabetes was caused by his hemorrhagic pancreatitis and pancreatectomy. Because the probative medical evidence of record confirms that Veteran’s diabetes mellitus is proximately due to nonservice-connected hemorrhagic pancreatitis as an intercurrent cause, the Board finds that the presumption of herbicide exposure is rebutted as a cause of the Veteran’s disability. See 38 C.F.R. § 3.307 (d)(2). In sum, the preponderance of the evidence is against entitlement to service connection for diabetes mellitus on a presumptive or nonpresumptive direct-incurrence basis, including as due to herbicide exposure. The benefit of the doubt does not apply, and the claim is denied. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). U. R. POWELL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Reed, Associate Counsel