Citation Nr: 1825880 Decision Date: 04/30/18 Archive Date: 05/07/18 DOCKET NO. 12-27 126 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUE Entitlement to service connection for type II diabetes mellitus, including as secondary to herbicide exposure or secondary to service-connected psoriasis. REPRESENTATION Veteran represented by: Paralyzed Veterans of America, Inc. ATTORNEY FOR THE BOARD J. Smith-Jennings, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1981 to February 1982. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. The Veteran requested a hearing in her September 2012 substantive appeal. A hearing was scheduled for April 2014. However, the Veteran withdrew her request in an April 2014 statement. In January 2015, the Board remanded the claim for additional development. The case now returns to the Board for appellate review. FINDING OF FACT The Veteran's type II diabetes mellitus was caused by her service-connected psoriasis. CONCLUSION OF LAW The criteria for service connection for type II diabetes mellitus are met. 38 U.S.C. §§ 1101, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran seeks service connection for type II diabetes mellitus. Specifically she contends that she has type II diabetes mellitus as a result of exposure to herbicides, including Agent Orange during basic training at Fort McClellan. Alternatively, the Veteran contends that her type II diabetes mellitus was caused or aggravated by her service-connected psoriasis. After review of the record, the Board concludes that service connection for diabetes mellitus secondary to psoriasis is warranted. Given this favorable finding, the Board need not address the Veteran's alternative theory of entitlement - exposure to herbicide agents. Generally, service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (a) (2017). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). Further, service connection may be established on a secondary basis for a disability which was either caused or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a) (2017); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical evidence. VA must also consider all favorable lay evidence of record. See 38 U.S.C. § 5107 (b) (2012); see also Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (a Veteran is competent to report on that of which he or she has actually observed and is within the realm of his or her personal knowledge). At the outset, the Board notes that the Veteran has a current diagnosis of type II diabetes mellitus which is confirmed by the evidence of record. More specifically, the evidence of record includes a March 2015 VA examination report in which the VA examiner confirmed a current diagnosis of type II diabetes mellitus. The Veteran's VA medical records also confirm a current diagnosis of type II diabetes mellitus. In addressing the medical nexus evidence, the Board requested a Veteran's Health Administration (VHA) advisory opinion from an endocrinologist in October 2017. The endocrinologist opined that psoriasis is a T-cell mediated inflammatory disease and the metabolic aspects of chronic inflammation have the potential to impact conditions such as type II diabetes mellitus. Body surface area matters. The greater the body surface area affected by psoriasis, the greater the risk of developing type II diabetes mellitus, independent of other risk factors, especially in those with greater than 10 percent body surface area affected. The endocrinologist further explained that psoriasis therapies, including but not limited to glucocorticoids, methotrexate, and cyclosporine, also may in and of themselves promote the development of diabetes. The record reflects that the Veteran was granted an increased rating in February 2008 for service-connected psoriasis affecting 21.5 percent of her body. See February 2008 Rating Decision (Granting 60% increased rating for service-connected psoriasis). The record also reflects that current treatment for her psoriasis includes the therapies identified by the October 2017 endocrinologist as those which promote the development of diabetes mellitus. Given that the area affected by psoriasis in this case exceeds 10 percent, and the Veteran has been prescribed therapies which promote the development of diabetes mellitus, the Board resolves all doubt in the Veteran's favor, and finds that service connection for type II diabetes mellitus is warranted. The Board acknowledges that the evidence of record includes a March 2015 VA examiner opinion concluding that it was less likely than not that the Veteran's type II diabetes mellitus was caused or aggravated by her service-connected psoriasis. However, the Board finds the March 2015 VA examiner opinion to be inadequate. The examiner acknowledged that the Veteran was rated at 60 percent for psoriasis and that there was some relationship between inflammation and metabolic syndrome, but did not address or account for the fact that a study found that there was a nearly two fold risk for developing diabetes if one has severe psoriasis. This omission is significant as the Veteran's psoriasis is severe. Moreover, the VA examiner neglected to address which risk factor most likely represented the Veteran's largest risk for developing diabetes, and whether that risk factor could as likely as not be related to psoriasis based on the findings of the study. In light of the foregoing, and resolving all doubt in the Veteran's favor, the Board finds that service connection for type II diabetes mellitus is warranted. Consequently, the benefit sought on appeal is granted. 38 U.S.C. §§ 1101, 5107; 38 C.F.R. §§ 3.303, 3.310. ORDER Service connection for type II diabetes mellitus is granted. ____________________________________________ S.C. KREMBS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs