Citation Nr: 21066525 Decision Date: 11/01/21 Archive Date: 11/01/21 DOCKET NO. 14-43 104 DATE: November 1, 2021 ORDER Entitlement to service connection for diabetes mellitus, type II, (DMII) to include as secondary to a service-connected left knee disability is granted. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDING OF FACT The Veteran's DMII is aggravated beyond its natural progression by his service-connected left knee disability. CONCLUSION OF LAW The criteria for service connection for diabetes as secondary to the Veteran's service-connected left knee disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the Army from December 1965 to March 1968. This case comes before the Board of Veterans' Appeals (Board) on appeal from an April 2013 and an April 2014 rating decisions by the Department of Veterans Affairs (VA) Regional Office. In November 2018 and November 2020, the Board remanded the claim for additional development. Entitlement to service connection for diabetes mellitus, type II, to include as secondary to a service-connected left knee disability. The Veteran seeks service connection for his DMII as secondary to his service-connected left knee disability. Specifically, the Veteran contends that the stress and bone infection resulting from his total left knee replacement caused his blood sugar levels to rise causing his DMII and needing insulin. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Service connection on a secondary basis may also be granted for a current disability proximately aggravated by a service-connected disability. 38 C.F.R. § 3.310 (b). Service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310 (b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Veteran underwent a VA examination in March 2014 for his diabetes. The examiner confirmed the Veteran's August 2013 diagnosis of DMII, and that it was managed by restricted diet and insulin. The examiner opined that it was less likely than not that the Veteran's DMII was proximately due to or the result of his service-connected total left knee replacement. The examiner, relying on medical literature, listed common risk factors for DMII, and said that a knee replacement, an infection, and stress from it are not listed as one of the risk factors for developing DMII. However, the examiner did not opine as to aggravation or provide a baseline prior to surgery for the Veteran's diabetes. In May 2014, P.A.-C L.H. provided a statement concerning the Veteran's diabetes. She opined that the Veteran's knee surgery and infection, accompanied by his stress levels, may have contributed to difficulty in getting his blood sugar under control. However, she emphasized that his diabetes would not be considered to be caused by his knee problems or stress. During a primary care visit the same day with the same provider, she reported telling the Veteran that while stress and infection are not going to cause diabetes, if diabetes was already present, it could worsen the blood sugars at that time. She clarified that without an underlying development of diabetes, his A1c would not have gone up above 10 with just stress and infection alone. The Veteran underwent another VA examination in October 2019 for his DMII. The examiner confirmed the Veteran's DMII diagnosis. She noted that the Veteran said he was diagnosed with diabetes in 2012 following his knee surgery, but that the review of the records showed he was diagnosed in August 2013, and there were no records of diabetes prior to that in the available record. She stated that DMII is caused by several risk factors, however, stress of having surgery does not cause diabetes. She said that a review of literature did not show surgery or stress of surgery as a causative or aggravating factor in diabetes and opined that it was less likely than not that the Veteran's diabetes was caused or aggravated (worsened beyond its natural progression) by his service-connected left knee disability. Then, in January 2021, the Veteran underwent another VA examination for his diabetes. The examiner confirmed his diabetes diagnosis and determined he also had neuropathy bilaterally in his hands and feet. She then indicated that patients who experience major trauma, illness, and surgery often develop hypermetabolic stress response, which is characterized by hyperglycemia and insulin resistance. However, she said that elevation of blood glucose due to the stress of illness is transient, and there is no data or research to demonstrate that stress of surgery or illness may result in a state of chronic hyperglycemia thereby leading to the development of or progression to DMII. She opined that since the Veteran had been treated for bilateral peripheral neuropathy prior to surgery, he likely was prediabetic, and according to the American Diabetes Association, 70 percent of people with prediabetes will eventually develop diabetes. She concluded that there was no evidentiary support for a causal relationship between his surgery/infection and the progression from pre-diabetes to DMII. The examiner also said she concurred with L.H.'s opinion concerning the Veteran's surgery, infection, and accompanying stress levels having contributed to difficulty controlling his blood sugar. She also said that it was well understood and not unusual for a diabetic to experience hyperglycemia and difficulty controlling glucose levels during an acute infection or illness; however, she said that there is no research or data to demonstrate an etiopathogenic causality between an infection/illness and the development of DMII. She added that stress induced hyperglycemia resolves with recovery and that it was likely that his infection contributed to increased glucose levels and difficulty maintaining optimal levels; however, his infections were not the pathophysiologic cause of his DMII. She also discussed there being no data or research to date that supports an etiopathogenic correlation between post-operative complications and the development of DMII. She opined that it was likely that his infection developed after his glucose was elevated; explaining that surgical patients commonly develop hyperglycemia related to hypermetabolic stress response which includes glucose production and causes insulin resistance. She pointed out, however, that even in critically ill patients, this occurrence is not long term, nor has it been found to contribute to the development of DMII. In April 2021, the Veteran's records were reviewed, and a VA endocrinologist opined as to the Veteran's diabetes. The examiner found that the Veteran's diabetes was less likely than not proximately due to or the result of the Veteran's service-connected left knee condition. He opined that the Veteran's left knee arthritis did not cause his diabetes, but that the infection in his left knee prosthesis did contribute to the Veteran's worsened hypoglycemia and subsequent diabetes condition. He stated that the Veteran did have a prediabetes condition based on his labs prior to his knee surgery, and that the knee disability did contribute to his increased diabetes risk. He opined that while the knee disability did not cause the diabetes, it did cause worsening hyperglycemia and glucose toxicity that caused his diabetes to flare and the Veteran suddenly having his hgA1c to go up to 12.3. Finally, in July 2021, an opinion clarifying whether the Veteran's DMII was caused by his left knee disability was added to the file. The doctor clarified his April 2021 opinion. He said that the Veteran was prediabetic prior to his knee surgery, but that it was transitioned into "full blown diabetes" after he was debilitated by his knee injury and subsequent knee sepsis. Clarifying that the Veteran's knee injury did contribute to the transformation of his prediabetes into full blown diabetes. As noted above, the VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. In the Veteran's March 2014 VA examination, the examiner did not provide an opinion as to the Veteran's baseline concerning his diabetes, and in his October 2019 VA examination, the examiner opined that the Veteran's surgery was not an aggravating factor in his diabetes. However, in the Veteran's January 2021 VA examination and the April 2021 review of the Veteran's records, the examiners both opined that prior to his surgery, the Veteran was prediabetic. The January 2021 examiner specifically stated that prior to the surgery, there was no documentation of hyperglycemia. Also, L.H. opined in May 2014 that if diabetes was already present, then the Veteran's surgery could have worsened the blood sugars at that time, emphasizing that without an underlying development of diabetes, the Veteran's A1C would not have gone up above 10 with just stress and infection alone. Based on the foregoing, the Board finds that the evidence as to the Veteran's baseline level of severity prior to his surgery and diagnosis of DMII, to be in relative equipoise. The VA examiners agree the Veteran's DMII was not proximately due to or caused by his service-connected left knee surgery; however, they also agree that his surgery worsened his condition and contributed to the diagnosis of diabetes. Since the establishment of the Veteran's baseline of severity for his diabetes is found to be in equipoise, the Board resolves all reasonable doubt in favor of the Veteran and finds that prior to his surgery, the Veteran suffered from prediabetes, and that it was worsened, and therefore aggravated, leading to a diagnosis of DMII, by his service-connected left knee condition. Therefore, secondary service connection for DMII is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND Entitlement to a total disability rating based on individual unemployability is remanded. The Veteran seeks a total disability rating due to individual unemployability. The Board finds that the claim for service connection for DMII, granted herein, and the claim of entitlement to a TDIU are inextricably intertwined. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both issues have been considered). The claims of entitlement to service connection for DMII and TDIU are "intertwined" because a rating evaluation on the DMII claim will impact the claim for a TDIU. Consequently, the claim of entitlement to TDIU benefits must be remanded. The matter is REMANDED for the following action: 1. Evaluate the Veteran's service-connected DMII for rating purposes. 2. After completing the above, and any other development deemed necessary, readjudicate the Veteran's claim of entitlement to a TDIU. J. B. FREEMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Doerfler, 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.