Citation Nr: 21063378 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 17-50 436 DATE: October 14, 2021 ORDER Entitlement to service connection for diabetes mellitus, type II (DMT2), to include as secondary to the service-connected disability of sarcoidosis, is denied. FINDING OF FACT The evidence fails to establish that the Veteran's DMT2 is due to a disease or injury in service or was caused or aggravated by his service-connected sarcoidosis. CONCLUSION OF LAW The criteria for service connection for DMT2 have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1966 to August 1970. This matter is before the Board of Veterans' Appeals (Board) on appeal from an August 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in March 2019. At that time, the Board reopened the claim for service connection for DMT2 denied in an unappealed and final September 2010 rating decision. The Board also remanded the claim for additional development to include a VA examination to address the nature and etiology of his DMT2 to include a claim of secondary service connection raised in the Veteran's September 2017 VA Form 9. The Board notes that, to the full extent possible, VA complied with all prior remand instruction requests, and no deficiencies in VA's duties to notify and assist exist in that regard. See Stegall v. West, 11 Vet. App. 268 (1998); but see D'Aries v. Peake, 22 Vet. App. 97, 104 (2008). The matter has returned to the Board for appellate review. Service Connection In general, service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or a disease incurred or aggravated in the line of duty during 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, 1131; 38 C.F.R. § 3.303(a). 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 disease or injury in service and the current disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. However, VA will not concede aggravation unless the baseline level of severity of the non-service-connected disease is established by medical evidence. 38 C.F.R. § 3.310(b). To prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). 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). A Veteran is competent to report on that of which he has actually observed and is within the realm of his personal knowledge. Layno v. Brown, 6 Vet. App. 465 (1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Board acknowledges that the Veteran has a current diagnosis of DMT2. See October 2019 VA diabetes mellitus examination. Therefore, the only questions for the Board are whether the Veteran's current disability began during service or is at least as likely as not related to an in-service injury, event, or disease, or in the alternative directly caused by, proximately due to, or aggravated by his service-connected sarcoidosis. The Veteran's STRs are silent as to a diagnosis, complaints of, or treatment for symptoms related to DMT2. The STRs include a November 1965 report of medical history (RMH) for enlistment wherein the Veteran denied sugar or albumin in his urine. November 1965 and March 1970 reports of medical examination (RME) are silent as to a diagnosis of DMT2. A June 1970 Medical Board Report noted laboratory results, including blood sugar levels, within normal limits. Post service treatment records include multiple records noting the Veteran's A1c levels including August 2009 A1c of 8.5 mg/dL, June 2009 A1c of 8.8 mg/dL, December 2009 A1c of 7.1 mg/dL, March 2010 A1c of 7.1 mg/dL, October 2014 A1c of 6.6 mg/dL, May 2015 A1c of 6.4 mg/dL, December 2016 A1c of 7.2 mg/dL, October 2017 A1c of 6.6 mg/dL, May 2019 A1c of 6.5 mg/dL, November 2019 A1c of 6.9 mg/dL. An October 2019 primary care record noted the Veteran was requesting a refill of insulin. The claims file includes an October 2019 VA DMT2 examination and medical opinion. The report notes an in-person examination and file review. The examiner confirmed a diagnosis of DMT2 from December 1999 and indicated that the Veteran's treatment plan includes restricted diet, prescribed oral hypoglycemic agents, and insulin by injected more than one time per day. Laboratory results dated October 2019 show glucose levels of 184 mg/dL (outside the reference range of 65-99 mg/dL). In a November 2019 medical opinion, the examiner opined that the Veteran's DMT2 was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As a rationale for the opinion, the examiner noted that the Veteran was diagnosed with DMT2 in the early 1990s, many years after separation from active duty. There are no records showing any incident during active duty that contribute to and/or cause the current DMT2. In a separate November 2019 medical opinion, the examiner addressed service connection based on a secondary theory, opining it is less likely than not (less than 50 percent probability) that the Veteran's DMT2 was proximately due to or the result of the Veteran's service-connected sarcoidosis. As a rationale, the examiner noted there is no direct pathophysiologic link between DMT2 and sarcoidosis. In addition, there is no direct causality or any medical literature directly linking sarcoidosis causing or contributing to diabetes mellitus. The examiner also provided a medical opinion that addressed entitlement to service connection based on aggravation. The examiner noted a baseline level of severity could not be established. Regardless, the examiner opined that the Veteran's DMT2 is not at least as likely as not aggravated beyond its natural progression by the Veteran's service-connected sarcoidosis. To support this opinion, the examiner noted again that there is no direct pathophysiologic link between diabetes and sarcoidosis and no medical literature directly linking sarcoidosis affecting and/or contributing to the worsening of DMT2. In this case, the Board notes that the earliest treatment of record for DMT2 is from decades after the Veteran's discharge from service. This passage of time is not determinate but is a factor for consideration when making a finding of direct service connection. After a thorough review of the claims file, the Board is unable to identify VA treatment, private treatment, or STRs suggesting complaints of or treatment for DMT2 prior to 1999. There are no other medical opinions of record addressing the nature and etiology of the Veteran's diagnosed DMT2. Simply stated, the medical evidence of record fails to suggest a correlation between active service and the Veteran's DMT2 or that secondary service connection is warranted. Finally, as indicated in 38 C.F.R. § 4.119, DC 7913, DMT2 is an internal disease of the endocrine system, subject to glucose tolerance testing. It is not one of the types of disorders (e.g., tinnitus, headaches) that may be capable of self-diagnosis. The Veteran has not established the training or credentials to establish a DMT2 diagnosis. Accordingly, the Veteran's lay contentions as to the as to the relationship between his DMT2 and his sarcoidosis do not represent competent evidence and lack probative value for the purposes of the decision at hand. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). For these reasons, the Board finds that the weight of competent medical evidence is against finding that the Veteran's DMT2 is related to his active service or that he developed DMT2 within a year of service, or, in the alternative, that DMT2 is secondary to or aggravated by his service-connected sarcoidosis. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The claim for service connection must therefore be denied. A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Banks, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.