Citation Nr: 18153968 Decision Date: 11/29/18 Archive Date: 11/28/18 DOCKET NO. 16-43 558 DATE: November 29, 2018 ORDER Entitlement to service connection for an above-the-knee amputation of the right leg is granted. FINDING OF FACT Resolving reasonable doubt in the Veteran’s favor, his above-the-knee amputation of the right leg is proximately due to his service-connected diabetes mellitus, type II (DM). CONCLUSION OF LAW The criteria for secondary service connection for an above-the-knee amputation of the right leg are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from January 1968 to September 1969 with service in the Republic of Vietnam. Initially, the Board would like to note that the Veteran originally filed his claim for service connection for a below-the-knee amputation of the right leg in June 2013. In November 2013, he underwent an above-the-knee amputation of the right leg. Accordingly, the Board has recharacterized the issue above. 1. Entitlement to service connection for an above-the-knee amputation of the right leg Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Generally, the evidence 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, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (noting that nexus may be demonstrated by a showing of continuity of symptomatology where the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a)). Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); Allen v. Brown, 8 Vet. App. 374 (1995). In order to prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); see also Allen, supra. The Veteran contends that his above-the-knee right leg amputation was caused by his service-connected DM. Report of Contact, February 2014. Therefore, he believes service connection is warranted on a secondary basis. With regard to a present disability, the Veteran underwent a below-the-knee right leg amputation in April 2013. Operative report, April 2013. After the wound did not heal, he underwent an above-the-knee right leg amputation in November 2013. Operative report, November 2013. The first elements of Shedden/Caluza and Wallin are met. With regard to an in-service event, the Veteran’s service treatment records are negative for any complaints or treatment relating to his right leg. However, the Veteran does not claim that he had an in-service right leg disorder or amputation. Rather, he claims that his right leg amputation is secondary to his service-connected DM. The record does show that he is service connected for DM, as well as coronary artery disease. The second Wallin element is met. The remaining question is whether there is a medical nexus between the Veteran’s currently diagnosed above-the-knee right leg amputation and his service-connected DM. The Veteran was afforded a VA examination to address his right leg amputation in March 2014. VA examination, March 2014. The examiner concluded that the Veteran’s amputation was more likely due to his peripheral artery disease (PAD) with significant risk factors of smoking and hypertension. Although she did not opine that the DM caused his amputation, she noted that patients with DM have more advanced arterial disease at the time of their initial diagnosis and poorer outcomes than non-diabetics. This seems to suggest some relationship between DM and PAD. Despite this suggestion, the examiner did not address whether the Veteran’s DM aggravated his PAD. The evidence also includes two private records that also support a link between the Veteran’s DM and his eventual right leg amputation. Specifically, an April 2011 private treatment record addressing the Veteran’s left leg PAD symptoms notes that they are likely due to DM and smoking. Private treatment record, April 2011. This again suggests a link between the Veteran’s PAD and his DM. Additionally, a July 2013 private treatment record following the Veteran’s below-the-knee right leg amputation indicates that he developed a diabetic ulcer following this surgery. Private treatment record, July 2013. This ulcer and the non-healing wound ultimately led to the above-the-knee amputation. Most significantly, the Veteran submitted a September 2015 letter from his private physician opining that the cause of his vascular disease was multifactorial and that his risk factors included a history of smoking, hyperlipidemia, hypertension, and DM. Dr. M.L.S. letter, September 2015. He concluded that each of these risk factors, including DM, ultimately led to his above-the-knee amputation. The Board notes that the Veteran’s claim could be remanded for a VA opinion that addresses the issue of aggravation, as well as the positive evidence that was not considered in the prior VA opinion. However, in light of the competent private opinion, other supporting positive evidence, and lack of adequate contradictory negative evidence, the Board finds that the evidence is, at a minimum, in equipoise regarding the question of whether the Veteran’s current above-the-knee right leg amputation is related to his service-connected DM. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.310. The benefit of the doubt will be conferred in the Veteran’s favor and remand is not necessary. The service-connection claim for an above-the-knee right leg amputation is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). (Continued on the next page)   As the Veteran’s claim for service connection has been granted on a secondary basis, any further discussion of service connection on a direct basis is not necessary. YVETTE R. WHITE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Moore, Counsel