Citation Nr: 18112409 Decision Date: 06/19/18 Archive Date: 06/19/18 DOCKET NO. 12-11 726 DATE: June 19, 2018 ORDER Entitlement to service connection for diabetes mellitus, type II, to include as secondary to a service-connected disability, is denied. FINDING OF FACT The Veteran’s diabetes mellitus, type II, did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; it is not otherwise etiologically related to an in-service injury, event, or disease; and it is neither proximately due to nor aggravated beyond its natural progression by any service-connected disability. CONCLUSION OF LAW The criteria for service connection for diabetes mellitus, type II, are not met. 38 U.S.C. §§ 1110, 1112, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a), 3.310(a) (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1973 to November 1975. The appellant is the Veteran’s surviving spouse. This matter is on appeal from an August 2009 rating decision. The Veteran testified before the undersigned Veterans Law Judge during a January 2015 hearing. This matter was previously before the Board in May 2015 and September 2017, when it was remanded for additional development. Following the issuance of a September 2016 rating decision denying service connection for the Veteran’s cause of death, the appellant submitted medical evidence in March 2017 regarding the Veteran’s cause of death that does not appear to have been addressed by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over this issue, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2017). Entitlement to service connection for diabetes mellitus, type II, to include as secondary to a service-connected disability. Service connection is granted on a direct basis when there is competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Service connection for chronic diseases listed in 38 U.S.C. sections 1101(3) and 38 C.F.R. § 3.309(a), including diabetes mellitus, type II, may be established on a presumptive basis if the chronic disease was shown as chronic in service; manifested to a compensable degree within a presumptive period, usually one year, after separation from service; or was noted in service with continuity of symptomatology since service. 38 U.S.C. §§ 1112, 1113; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). Service connection may also be granted for a disability that is proximately due to or the result of an established service-connected disability. 38 C.F.R. § 3.310 (2017). This includes disability made chronically worse by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran contended that his diabetes mellitus, type II, was related to his service-connected depression, chronic low back strain, bilateral lower extremity radiculopathy, and small hiatal hernia with mild antral gastritis disabilities. Specifically, the Veteran contended that factors such as inactivity and/or chronic pain associated with his physical disabilities and/or his depression may have caused or aggravated his diabetes mellitus, type II. The central question for the Board is whether the Veteran’s diabetes mellitus, type II, was proximately due to or the result of, or was aggravated beyond its natural progress by any service-connected disability. The Board concludes that, while the Veteran has a current diagnosis of diabetes mellitus, type II, the preponderance of the evidence is against finding that the Veteran’s diabetes mellitus, type II, is proximately due to or the result of, or aggravated beyond its natural progression by any service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The November 2016 VA staff physician opined that it was less likely than not that the Veteran’s diabetes mellitus, type II, was caused by, or aggravated by, any service-connected disability. The examiner noted that the Veteran was service-connected for right leg radiculopathy, left leg radiculopathy, chronic low back strain, and small hiatal hernia with mild antral gastritis. The rationale was that no one of these problems is known to cause diabetes mellitus. The physician explained that although inactivity has been proposed to participate as a risk factor in the development of diabetes, inactivity by itself is not a cause of diabetes, nor a significant contributory factor. The physician explained further that diabetes was not aggravated, as the Veteran’s last A1c in December 2015, two months before his death, was at 7.3, and reported as controlled. The physician noted further that the Veteran was diagnosed with diabetes a few months after his, after he was placed on Prednisone treatment as part of his immunosuppressive treatment, and this could be a participating etiology of the diabetes mellitus, type II. The November 2016 VA staff physician provided an addendum opinion in March 2018, which addressed the Board’s concerns with the November 2016 opinion. The physician again opined that the Veteran’s diabetes mellitus, type II, was less likely than not caused or aggravated by his service-connected disabilities, to include his chronic low back strain, bilateral lower extremity radiculopathy, or small hiatal hernia with mild antral gastritis. The rationale for no causation was that although inactivity has been proposed to participate as a risk factor in the development of diabetes, it was not a cause or significant contributory factor in the development of diabetes. The staff physician explained that diabetes is a multifactorial disease, where genetic and environmental factors, such as excess weight and in activity seem to be contributing factors, but not causal. The physician explained how the medical literature submitted by the Veteran supported this conclusion. The physician noted that the literature recommended being active not because inactivity caused diabetes, but because inactivity could increase the risk of having diabetes. The physician’s rationale for no aggravation was that there was no evidence of aggravation as the last A1c in December 2015, two months before the Veteran’s death, was at 7.3, and reported as controlled. Additionally, the April 2018 VA staff psychiatrist opined that it was less likely than not that the Veteran’s service-connected depression caused or aggravated the Veteran’s diabetes. The rationale was that diabetes is a multifactorial disease and depression is not known in the medical literature to cause or exacerbate diabetes. The psychiatrist explained that although depression may cause alterations in sleep or dietary habits, establishing any relationship between depression and diabetes in any specific individual would be merely speculative. The Board finds the VA opinions, taken as a whole, are adequate and reliable, and affords them great probative weight. The Board is particularly persuaded to assign great probative weight to the March 2018 and April 2018 opinions because the VA staff physician and psychiatrist reviewed the claims file and provided a rationale for the conclusion that was grounded in the evidence of record. The Board acknowledges that the April 2018 VA psychiatrist indicated that establishing any relationship between depression and diabetes in any specific individual would be merely speculative. However, the Board observes that he nonetheless provided an adequate rationale for his opinion that it was less likely than not the Veteran’s depression caused or aggravated the Veteran’s diabetes. Moreover, there is no competent medical evidence to refute the conclusions of the VA physicians or to otherwise establish a link between the currently diagnosed diabetes mellitus, type II, and any service-connected disability. The Board has considered the medical literature submitted by the Veteran, but finds that it is of limited probative value. In this regard, the Veteran submitted various medical articles in support of his claim concerning diabetes, depression and stress, and physiological responses to pain. However, the Board finds that these articles provided only general information that is not specific to the particular facts of this case. The Board finds that the VA medical opinions are more probative, because they were a product of consideration of the Veteran’s relevant history as well as medical literature and included a rationale specific to the Veteran. Considering the above, the Board finds that the opinions of record, taken as a whole, adequately explain why the Veteran’s diabetes mellitus, type II, was not caused or aggravated by his service-connected depression, chronic low back strain, bilateral lower extremity radiculopathy, and small hiatal hernia with mild antral gastritis disabilities. While the Veteran believed his diabetes mellitus, type II, was proximately due to or the result of/aggravated beyond its natural progression by the inactivity caused by his service-connected disabilities, he was not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the VA opinions. As such, there is no basis for secondary service connection. Service connection may also be granted on a direct basis, but the preponderance of the evidence is also against finding that the Veteran’s diabetes mellitus is related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Notably, throughout the course of the current appeal, the Veteran and the appellant have not advanced any arguments or medical evidence relating his diabetes to service on a direct basis. There were no findings of diabetes mellitus in the service treatment records. Thus, the Veteran had no in-service evidence of diabetes mellitus. Nor does the claims file otherwise include lay evidence of continuity of symptomatology since service, or evidence that a competent medical professional has linked the Veteran’s current diabetes mellitus, type II, to his service. In this regard, the post-service treatment records show a diagnosis of diabetes mellitus, type II, in or around 2004 or 2005, decades after service. See, e.g., VA problem list noting an onset of diabetes mellitus, type II, in January 2005; see also Kingston Diagnostic Group private treatment records dated in 2004 noting a diagnosis of diabetes mellitus, type II. In the absence of such evidence, service connection may not be granted. Moreover, the November 2016 VA physician noted that the Veteran was diagnosed with diabetes a few months after his transplant, after he was placed on Prednisone treatment as part of his immunosuppressive treatment, and explained that this could be a participating etiology of the diabetes mellitus, type II. Further, although diabetes mellitus, type II, is a chronic disease under 38 C.F.R. § 3.309(a), it did not manifest to a compensable degree in service or within a presumptive period, and continuity of symptomatology is not established. 38 U.S.C. §§ 1101(3), 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). As noted above, VA and private treatment records show the Veteran was not diagnosed with diabetes mellitus until decades after his separation from service and well outside of the applicable presumptive period. The Board recognizes that VA has not obtained a medical opinion on direct service connection and has considered whether such development is warranted. However, in the instant case, the record does not indicate that the Veteran’s diabetes mellitus disability may be associated with service. Specifically, the Veteran has not reported experiencing recurrent symptoms or continuity of symptomatology since service or provided any other indication of an association with service. For these reasons, a VA medical opinion is not necessary to decide the claim for service connection for diabetes mellitus, type II. Id. at 81; 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i)(C). In this case, the Board ultimately places far more probative weight on the lack of clinical findings or complaints of diabetes mellitus during active duty service, on separation from service, and for decades after service, and the negative VA medical opinions of record. As such, the Board finds that service connection for diabetes mellitus, type II, is not warranted. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. T. Brant, Counsel