Citation Nr: 21068436 Decision Date: 11/10/21 Archive Date: 11/10/21 DOCKET NO. 16-14 765 DATE: November 10, 2021 ORDER Entitlement to service connection for residuals of a stroke secondary to diabetes mellitus is denied. Entitlement to service connection for chronic kidney disease secondary to diabetes mellitus is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran has had residuals of a stroke or any related disability at any time during or approximate to the pendency of the claim. 2. The preponderance of the evidence is against finding that the Veteran's chronic kidney disease is secondary to service-connected diabetes mellitus, or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for residuals of a stroke, as secondary to diabetes mellitus have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for chronic kidney disease, as secondary to diabetes mellitus have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1969 to July 1990. These matters are before the Board of Veterans' Appeals (Board) on appeal from a February 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In February 2019, the Veteran testified before the undersigned Veterans Law Judge at a hearing; a copy of the transcript is associated with the claims file. The Board remanded the appeal in July 2019 and September 2020. There has been substantial compliance with the remand directives. Service Connection The Veteran seeks service connection for chronic kidney disease and residuals of stroke as secondary to his service-connected diabetes mellitus. See October 2014 VA 21-526EZ. Because the Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board's adjudication will consider only entitlement to secondary service connection for these issues. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. 1. Entitlement to service connection for residuals of a stroke, as secondary to diabetes mellitus is denied. The Veteran asserts that he has residuals of a stroke, secondary to his service-connected diabetes mellitus. The existence of a current disability is the cornerstone of a claim for VA disability compensation. In the absence of proof of a disability during that period, there is no valid claim of service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). The threshold question that must be addressed then (as with any claim seeking service connection), is whether the Veteran actually has had the disability for which service connection is sought, at any time during the period on appeal. Based on review of the evidence, the Board concludes that the Veteran does not have a current disability, claimed as residuals of a stroke, and has not had such at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran filed his claim seeking service connection for residuals of a stroke in October 2014. In September 2014, the Veteran's private clinician (Dr. M.K.) completed a Diabetes Mellitus Disability Benefits Questionnaire (DBQ), VA Form 21-0960E-1. In 'Section III- Complications of Diabetes Mellitus' Dr. M.K. identified a stroke as one of the Veteran's conditions due to diabetes mellitus. The DBQ indicates that if a clinician checks the box to indicate a stroke as a diabetes mellitus residual, he or she is to complete the additional indicated forms - VA Form 21-0960C-3, Cranial Nerve Conditions DBQ and/or VA Form 21-0960C-5, Central Nervous System and Neuromuscular Diseases DBQ. Dr. M.K. did not complete either form. He also provided no further explanation for this finding in the free-text box 'Section VII-Remarks' to indicate when the stroke had occurred and whether there were any current stroke residuals. VA and private medical records reflect a medical history of cerebrovascular accident (CVA) and transient ischemic attack (TIA). VA treatment records primarily reflect findings of CVA/TIA only in the Veteran's past medical history, although there are a few records that show 's/p CVA in 2015-TIA several' in a diagnosis list. Notably, none of the medical records identify a CVA or TIA as a current medical problem, nor identify any specific current residuals related to those past events. For instance, private treatment records dated in June 2018 did not mention a recent stroke in the complaints and a neurological examination showed grossly intact cranial nerves. Private treatment records likewise indicate a remote of CVA and/or TIA. Specifically, the records reflect findings of such in the Veteran's past medical history or past medical problem lists. Notably, during a January 2015 VA examination for posttraumatic stress disorder, the Veteran reported that he had several CVAs and TIAs in 2007 when he had very high blood pressure. He denied subsequent events. The Veteran was afforded a VA examination in January 2020 to evaluate his service-connected diabetes mellitus. The examiner identified a stroke as a residual of the Veteran's diabetes mellitus. However, she further indicated that the Veteran is a poor historian as it relates to the time of onset of his health conditions. She noted that he believes he had a TIA, but did not know for sure or when it occurred. The Board remanded the appeal in September 2020 for an addendum opinion regarding the claimed stroke residuals. An addendum opinion was obtained in November 2020. The examiner reviewed the September 2014 private DBQ, the January 2020 VA examination report, and VA and private treatment records. Based on the review of the file, the examiner indicated that there is no medical evidence to support a stroke. In particular, the examiner indicated that her review of the file did not yield medical evidence to support current stroke residuals. The Board finds the November 2020 opinion probative because the examiner has the appropriate training, expertise, and knowledge to evaluate the claimed disability. The examiner provided a cogent opinion and rationale based on her consideration of the Veteran's reported symptoms and the relevant clinical history. Furthermore, the examiner reviewed the entire claims file, and her finding is consistent with the evidentiary record. The competent and most probative evidence of record does not establish a current disability of stroke residuals. The September 2014 DBQ does not provide sufficient explanation as to whether and when the Veteran experienced a stroke, or whether he had any stroke residuals manifest during the pendency of this appeal. That clinician failed to complete the associated cranial nerve and central nervous system DBQs that may have shed the necessary additional light on this question. Dr. M.K. also did not provide any rationale in that DBQ to explain what residuals were present or how he was able to identify a stroke as a condition due to the service-connected diabetes mellitus. Moreover, while the January 2020 VA examiner noted the Veteran self-reported a history of stroke, she also indicated that he was a poor historian and could not provide any details as to when it had occurred. The November 2020 VA examiner reviewed the entire claims file and was unable to find clinical evidence to support the existence of a current stroke or stroke residuals. Likewise, the Board's review of the medical records showed that his treating clinicians only identified a stroke and TIA as part of the Veteran's past medical history. The clinical notes and diagnoses did not include such as current medical problems, nor do they identify any specific current residuals related to those past medical events. The Veteran has not asserted that he experiences any specific medical symptoms related to past strokes or TIA, or any impaired earning capacity due to such. See generally, Saunders v. Wilkie, 886 F.3d 1356, 1364-65 (Fed. Cir. 2018). Moreover, while the Veteran believes he has a current diagnosis of residuals of stroke, he is not competent to provide such a diagnosis. That is a medically complex determination, as it requires specialized medical education and the ability to interpret complicated diagnostic medical testing. The Veteran is not shown to have the necessary medical training to render such a diagnosis. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). In the absence of a current diagnosis for the claimed condition, service connection is not warranted. See Brammer v. Derwinski, 3 Vet. App. 233, 225 (1992). In sum, the preponderance of the evidence weighs against the claim and there is no reasonable doubt to be resolved in this instance. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection for residuals of a stroke is not warranted. 2. Entitlement to service connection for chronic kidney disease, as secondary to diabetes mellitus is denied. At the February 2019 Board hearing, the Veteran testified that his kidney disease is secondary to his service-connected diabetes mellitus. See also October 2014 VA 21-526 EZ. The question for the Board is whether the Veteran's current chronic kidney disease is proximately due to or was aggravated beyond its natural progress by service-connected disability diabetes mellitus. In this regard, the Veteran submitted the September 2014 private disability benefit questionnaire for kidney conditions. The clinician noted a diagnosis of nephrolithiasis in 2012. However, the clinician did not indicate a diagnosis of diabetic nephropathy. The claims file also includes a September 2014 private disability benefit questionnaire for diabetes mellitus completed by the same clinician. The evaluation did not show a renal condition as due to diabetic complications. Likewise, a January 2020 VA examination for diabetes mellitus did not endorse renal complications. Pursuant to the Board's September 2020 remand directives, VA obtained an opinion in November 2020. The examiner reviewed the private and VA examinations of record, as well as the relevant treatment records. The examiner provided an unfavorable opinion as to whether the Veteran's chronic kidney disease was proximately caused or aggravated by service-connected diabetes mellitus. The examiner explained that the September 2014 diagnosis of nephrosclerosis is a hardening of the walls of the small blood vessels of the kidneys. The examiner further indicated that this condition may progress to cause chronic kidney disease; however, the examiner explained that the most common etiology is hypertension, and the Veteran has a history of hypertension. In the November 2020 opinion and the December 2020 addendum, the examiner indicated that the Veteran's chronic kidney disease has followed the normal progression. Therefore, there was no aggravation of the Veteran's chronic kidney disease by the service-connected disability. The Board finds the November 2020 and December 2020 VA opinions are the most probative evidence on the matter of causal nexus. The examiner was competent to evaluate the claimed disability. The examiner provided a thorough and cogent rationale in support of the opinions, which included consideration of the reported symptoms and the clinical history. Furthermore, the examiner reviewed the treatment records. However, the examiner indicated there are no diabetic kidney complications and specifically indicated that the Veteran's diagnosed chronic kidney condition was not etiologically related to his service-connected diabetes mellitus. These opinions provided the Board with a clear description of all relevant data points necessary to evaluate this claim. Comparatively, there are no competent and credible opinions to the contrary. While lay persons may be competent to provide the diagnoses of simple conditions, they are not competent to provide evidence on more complex medical questions beyond simple observations. See Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). In this case, the issue is medically complex because it requires knowledge of the interaction between multiple organ systems in the body. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Consequently, the Veteran's lay opinion is not competent and has little probative value. To the extent that any treatment records identified the Veteran as having kidney complications from diabetes mellitus, this is not an opinion nor an equally probative opinion. The Board has considered the September 2019 private treatment records, and others which noted a diagnoses of diabetes mellitus with other diabetic kidney complications. The treatment records did not support any etiological opinion with a rationale. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (a medical opinion that contains only data and conclusions is accorded no weight). As such, the incidental findings in treatment records are not afforded probative weight as to this claim. (Continued on the next page) The preponderance of the evidence is against the Veteran's claim of secondary service connection for his chronic kidney disease. As such, the benefit of the doubt doctrine is not applicable. Service connection for chronic kidney disease is not warranted. D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Vuong, 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.