Citation Nr: 21067593 Decision Date: 11/04/21 Archive Date: 11/04/21 DOCKET NO. 08-14 734 DATE: November 4, 2021 ORDER Entitlement to service connection for diabetes mellitus, to include as secondary to medication prescribed to treat a service-connected disability, is denied. FINDING OF FACT Diabetes mellitus was not manifested in service or within a year following the Veteran's separation from active duty, and his diabetes mellitus is not shown to have been etiologically related to his service, or to have been caused or aggravated by his service-connected skin disability or medication prescribed to treat the service-connected skin disability. CONCLUSION OF LAW Service connection for diabetes mellitus is not warranted. 38 U.S.C. §§ 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1981 to May 1984. He died in June 2018. The appellant is his surviving spouse and has been substituted for him as claimant/appellant for claims pending before VA when he died. This matter is before the Board on appeal from an October 2009 Department of Veterans Affairs (VA) rating decision. In October 2015, a Travel Board hearing was held before the undersigned; a transcript is in the record. In January 2016, October 2017, and August 2020, the matter was remanded for additional development. The Board's previous remands also addressed a claim for service connection for a skin disability. A July 2021 rating decision granted service connection for psoriasis vulgaris and seborrheic dermatitis, resolving that matter. Entitlement to service connection for diabetes mellitus, to include as secondary to medication prescribed to treat a service-connected skin disability, is denied. The appellant contends that the Veteran's diabetes mellitus arose during (was first manifested in or was otherwise etiologically related to) his active-duty service; or was either caused or aggravated by his service-connected skin disability and specifically by medication prescribed to treat the skin disability. The Veteran's STRs are silent for complaints, findings, treatment, or diagnosis of diabetes. On March 1984 service separation examination, the endocrine system was normal on clinical evaluation. On a contemporaneous report of medical history, he denied any history of frequent urination, recent gain or loss of weight, or sugar or albumin in urine. The Veteran indicated that while he was incarcerated, diabetes was diagnosed. On August 2007 VA treatment, he reported having a diagnosis of diabetes. The treatment records include diabetes mellitus in his active problem list in February 2008. He was seen in the diabetes clinic in October 2008 and assessed to have diabetes mellitus. On July 2010 VA examination, the Veteran reported that he was first informed that he had diabetes mellitus in July 2007, while he was incarcerated. He reported that he was told that his diabetes had been present "for quite some time". The examiner noted that a review of the STRs revealed no abnormal blood sugars or abnormal glucose findings. He currently took Metformin and saw a diabetic care provider; following a physical examination, the diagnosis was type II diabetes mellitus. On July 2011 VA treatment, diabetes was noted as an Axis III diagnosis on psychiatric treatment. On March 2012 VA treatment, the Veteran was noted to have a history of diabetes mellitus type 2, treated with metformin. In July 2013, he began treatment with insulin. In May 2015, he reported that his diabetes had been "cured" by weight loss. In August 2015, it was noted that he may not be diabetic, as he had not taken any glycemic medications for 2 years, after his A1C level was found to be high in 2012 and he was on insulin at that time. At the October 2015 Board hearing, the Veteran testified that he did not currently have diabetes, and had not been treated for it for the previous year and a half since his weight had regulated. He testified that he had been diagnosed with diabetes about 5 to 6 years prior. His wife testified that she believed that he developed diabetes as a side effect of taking prednisone to treat his skin condition. The claims file includes notifications from the Veteran in March 2018 and April 2018 (just prior to his death) indicating that he would not be attending an examination for diabetes, and requesting that VA render a decision in the matter without the exam. On April 2018 VA treatment, the Veteran's past medical history included "diabetes mellitus with prednisone, now resolved". On May 2018 VA treatment, the assessments included type 2 diabetes with hemoglobin A1c 7.5, May 21, 2018. In an October 2020 VA record review and advisory medical opinion, the provider a family medicine doctor opined that the Veteran's claimed diabetes mellitus is at least as likely as not (50 percent or greater probability) proximately due to or the result of his service-connected condition. The provider stated that the Veteran was diagnosed with type 2 diabetes mellitus in 2010. The provider noted that there are multiple treatment records in years prior to this diagnosis indicating that the Veteran sought treatment for skin conditions and many times was prescribed prednisone or received intralesional corticosteroid injections. The provider opined that, as elevated blood sugars are a documented adverse effect of prolonged or repetitive steroid use, it is at least as likely as not that the Veteran's type 2 diabetes mellitus is associated with or aggravated by his skin condition treatment. The provider opined based on a records review that the treatment of the skin conditions could have caused the type 2 diabetes mellitus, however uncontrolled type 2 diabetes is known to be associated with aggravation of skin conditions, so it could be that the diabetes caused aggravation of his skin issues. In a May 2021 VA record review and advisory medical opinion, the provider an endocrinologist noted that in March 2007, the Veteran was placed on a low dose of prednisone for one week at a dose that decreased every other day; this was not treatment for a skin condition, so the reason for the prednisone treatment is unclear. The provider noted that this was almost 18 months before diabetes was diagnosed and opined that it was not causally related to the onset of diabetes. The provider noted per an October 2008 treatment note that the diagnosis of diabetes was made while the Veteran was in prison, and there is no record of him receiving prednisone at that time. The provider opined that the Veteran's type 2 diabetes was not caused by the low dose of prednisone he received 18 months before the diabetes was diagnosed, and it likely was precipitated by weight gain during incarceration but, even with weight loss, it was present at least in 2017. The provider opined that the diabetes was not caused or aggravated in any way by the skin disability or medication prescribed to treat it. The provider explained that as a person ages, insulin production decreases in some individuals and weight gain and inactivity increase the need for insulin. The provider noted that the Veteran associated his weight changes with his increase and decrease in blood sugar levels and, though the diagnosis of type 2 diabetes is a chronic disease, blood sugar levels can increase or decrease from time to time related to certain variables including genetics. The provider opined that the Veteran's type 2 diabetes was less likely than not (less than 50 percent probability) proximately due to or the result of, or caused or aggravated by, his skin condition and/or treatment of any kind for it. In a July 2021 VA record review and advisory medical opinion, the provider a family practice doctor noted based on the 2010 VA examination that the Veteran was diagnosed with diabetes mellitus, however no record was found that will indicate symptoms, signs and diagnostic result to confirm the existence of the condition during service. The provider noted that the Veteran was diagnosed with diabetes mellitus in July 2007, which was many years after his separation from service. The provider noted that the Veteran was using a topical ointment for his skin condition which does not have systemic complication including diabetes. The provider opined that, in this case, diabetes is related to a problem with insulin production and insulin resistance, a condition due to the pancreas not being able to produce enough insulin to lower the blood sugar, which is the most common cause of non-insulin dependent diabetes (type 2 diabetes mellitus). Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). To substantiate a claim of service connection, there must be evidence of (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). A disease first diagnosed after service may be service connected if all the evidence, including pertinent service records, establishes that it was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Certain chronic diseases, to include diabetes mellitus, may be presumed to be service-connected if manifested to a compensable degree within a specified period postservice (one year for diabetes mellitus). 38 U.S.C. § 1137; 38 C.F.R. §§ 3.307, 3.309(a). Nexus of a chronic disease listed in § 3.309(a) to service may be established by showing continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013). Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease, will be service connected. VA will not concede that a non-service-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. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities and determine the extent of aggravation by deducting the baseline level of severity, and any increase in severity due to the natural progress, from the current level. 38 C.F.R. § 3.310(b). The Veteran has established service connection for, in pertinent part, psoriasis vulgaris and seborrheic dermatitis. Diabetes mellitus is not shown to have been manifested in service and is not noted in postservice clinical records in the record prior to 2007. Accordingly, service connection for such disability on the basis that it became manifest in service and persisted, or on a chronic disease presumptive basis under 38 U.S.C. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309(a), is not warranted. It is not shown by the record that the Veteran's diabetes mellitus was related directly to his active duty service. The earliest documented postservice clinical notation of complaints pertaining to diabetes mellitus is in 2007, approximately 23 years after the Veteran's separation from active service. The Board notes that the October 2020 opinion by a VA provider supporting the claim and explaining that elevated blood sugar is a known side-effect of prolonged and repetitive corticosteroid use (noting that there are multiple records showing the Veteran received treatment with corticosteroid injections). However, as was noted by a later consulting provider, the record does not show that the Veteran received prolonged and repetitive steroids for his service-connected skin disability. Instead, the record shows a single low-dose, with gradual reduction of dosage, course of treatment with prednisone, 18 months prior to the diagnosis of diabetes (so not an apparent effect), which was not for the service-connected skin disability. As the opinion was based on an inaccurate factual premise, it lacks probative value in this matter. Otherwise, VA examiners have opined that it is less likely than not that the diabetes mellitus was incurred during, or caused by, his military service. Regarding secondary service connection, the 2021 VA reviewing providers opined that it is less likely than not that the Veteran's diabetes mellitus was caused or aggravated by his service-connected skin disability and/or medication prescribed to treat it (explaining in essence that there is no pathophysiological basis for there to be a nexus between the diabetes mellitus and the service-connected skin disability). They cited to factual data and medical principles, and identified (citing to statistical support) more likely, non-service-related, alternate etiological factors for the Veteran's diabetes mellitus, including the aging process and weight gain. They noted that the Veteran was primarily treated for the service-connected skin disability by topical applications, which do not have an effect on the endocrine system. The providers include a physician who is an endocrinologist who would have particular expertise in diagnosing and determining the etiology of diabetes, and the opinions are probative evidence in the matter, and the Board finds them (cumulatively) persuasive. Whether the Veteran's skin disability and/or medication prescribed to treat it caused or aggravated his diabetes mellitus is a medical question that is beyond the scope of common knowledge and incapable of resolution by lay observation; it requires medical expertise. The appellant is a layperson; consequently, her own opinion is not competent evidence in this matter. See Jandreau, supra. She has not submitted a medical opinion with adequate rationale in support of this claim (or identified any medical provider who has offered such opinion). The preponderance of the evidence is against this claim, and the appeal in the matter must be denied. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Schechner, 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.