Citation Nr: 21068594 Decision Date: 11/10/21 Archive Date: 11/10/21 DOCKET NO. 14-28 865 DATE: November 10, 2021 ORDER Entitlement to service connection for familial hypertriglyceridemia is denied. Entitlement to service connection for pancreatitis, to include as proximately due to a service-connected disability to include major depressive disorder, or as a disease or injury superimposed upon the Veteran's familial hypertriglyceridemia, a congenital defect, is denied. Entitlement to service connection for diabetes mellitus, to include as proximately due to service-connected major depressive disorder, or as a disease or injury superimposed upon the Veteran's familial hypertriglyceridemia, a defect, is denied. FINDINGS OF FACT 1. The most probative medical evidence of record suggests the Veteran's familial hypertriglyceridemia is a genetic defect, precluded from service-connection as a matter of law; nor is aggravation by superimposed disease shown. 2. The most probative evidence of record weighs against finding the Veteran's pancreatitis began during active service, is related to an in-service injury or disease, or is proximate to a service-connected disability, to include major depressive disorder, or superimposed upon his familial hypertriglyceridemia, a genetic defect. 3. The most probative evidence of record weighs against finding the Veteran's diabetes began during active service, is otherwise related to an in-service injury or disease, or proximate to his service-connected major depressive disorder, or superimposed upon his familial hypertriglyceridemia, a genetic defect. CONCLUSIONS OF LAW 1. Service connection for congenital or developmental defects is precluded by VA regulation. 38 C.F.R. §§ 3.303(c), 4.9. 2. The criteria for service connection for pancreatitis are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for service connection for diabetes mellitus are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran has active service from May 1992 to December 1994. This case is before the Board of Veterans' Appeals (Board) from a March 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran appeared before the undersigned Veterans' Law Judge at a January 2016 hearing. In July 2018 and March 2021, the Board remanded these matters to the RO for additional development. The Board finds there has been substantial compliance with the Board's remand directives in accordance with Stegall v. West, 11 Vet. App. 268, 271 (1998), and may proceed with appellate review. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38U.S.C. §§1110, 1131, 5107; 38C.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 that is proximately due to or the result of a service-connected disease or injury. Secondary service connection may be established for a nonservice-connected disability which is aggravated by a service-connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310 (b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). In addition, where a veteran asserts entitlement to a chronic disease but there is insufficient evidence of a diagnosis in service, service connection may be established under 38C.F.R. §3.303(b) by demonstrating a continuity of symptomatology since service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) Service connection may be granted for diseases, but not defects, of congenital, developmental or familial origin, as long as the evidence as a whole establishes that the conditions in question were incurred or aggravated during service within the meaning of VA laws and regulations. The terms disease and defects must be interpreted as being mutually exclusive. The term disease is broadly defined as any deviation from or interruption of the normal structure or function of any part, organ, or system of the body that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown. The term defects means structural or inherent abnormalities or conditions that are more or less stationary in nature. VAOPGCPREC 82-90 (1990), 55 Fed. Reg. 45711 (1990). However, service connection may be warranted for such defects if there is superimposed pathology due to disease or injury in service. VAOPGCPREC 82-90 (July 18, 1990). 38 C.F.R. §§ 3.303(c), 4.9, 4.127. 1. Familial hypertriglyceridemia. The Veteran seeks service connection for familial hypertriglyceridemia, diagnosed in 1996 (08/24/2019 C&P Exam, pg. 2; 08/24/2019 C&P Exam, pg. 3). The Veteran asserts that his hypertriglyceridemia is a disease and had its onset in service (05/31/2014 VA 21-4138 Statement In Support of Claim; 04/23/2013 Congressionals). The Board recognizes the claim was denied because the RO found familial hypertriglyceridemia is not a disability, but rather a laboratory finding. In this regard, the Board notes hyperlipidemia is a general term for elevated concentration of any or all of the lipids in the plasma, including hypertriglyceridemia. See Dorland's Illustrated Medical Dictionary 792 (28th ed. 1994) at 795. Hyperlipidemia and elevated cholesterol are laboratory findings and are not disabilities in and of themselves for VA purposes. See 61 Fed. Reg. 20,440, 20,445 (May 7, 1996). Nonetheless, the Board previously found that the record warranted consideration of whether medical evidence, including in-service Veteran's blood levels of triglycerides, were sufficiently high to constitute a medical disability during service. The Veteran has also asserted that familial hypertriglyceridemia has been aggravated by his service-connected disabilities, to include his major depressive disorder. The Veteran has contended specifically his major depressive disorder has prevented him from complying with treatment plans causing or aggravating his hypertriglyceridemia (07/19/2021 Email Correspondence). The Board acknowledges the Veteran's belief that his hypertriglyceridemia had its onset in service or is related to an in-service injury, event, or disease, to include his service-connected major depressive disorder. However, the evidence of record does not suggest that the Veteran has specialized training or medical knowledge to make him competent to address the nature or etiology of his hypertriglyceridemia or provide diagnoses or nexus opinions regarding his theories of entitlement for hypertriglyceridemia. These issues are medically complex, requiring specialized knowledge and interpretation of complicated diagnostic medical testing. Finding this to be outside the competence of the Veteran, the Board cannot assign his lay statements probative weight as to diagnoses or nexus. Consequently, the only probative evidence of record are statements from medical professionals. Turning to the medical evidence, a review of the service treatment records do not include an in-service diagnosis with or treatment for familial hypertriglyceridemia. The Board acknowledges that elevated triglycerides were noted in labs associated with his separation physical. Nonetheless, upon separation, the Veteran was clinically evaluated as normal, and found qualified for separation (04/20/2014 STR Medical, pgs. 7, 11, and 12). As discussed below, the June 2019 examiner opined that the Veteran's elevated triglyceride levels were so minimally elevated to be clinically insignificant, and no diagnosis of hypertriglyceridemia was warranted or rendered during service (08/24/2019 C&P Exam). As mentioned, the Veteran was afforded a June 2019 VA examination that addressed the nature of his familial hypertriglyceridemia. The examiner explained that the Veteran's hypertriglyceridemia is clearly a familial type, inherited and not acquired. The examiner ultimately opined the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The June 2019 examiner explained that while Veteran does not have documentation of high triglyceride values prior to time in service, the condition that would develop into hypertriglyceridemia already existed prior to his time in service. As his hypertriglyceridemia is an inherited condition, the Veteran's hypertriglyceridemia did not develop in service and was not due to any event in service. The examiner noted the Veteran had triglyceride level of 163, with the normal range being 40-160 during his November 1994 separation examination (04/20/2014 STR - Medical). The examiner explained that the it is not clear whether the lab test was drawn in fasting state and triglyceride results are sensitive to high calorie and fat intake in the 12 hours prior to testing, as well as any intake immediately prior to the testing. The examiner noted that the Veteran had a retest of triglycerides with level 165 (normal range 40-160). Again, fasting details are not provided. The examiner opined that given absence if clarification regarding fasting, and that the Veteran's elevated triglyceride levels were so minimally elevated as to be clinically insignificant, no diagnosis of hypertriglyceridemia was warranted or rendered during service. (08/24/2019 C&P Exam). A May 2021 record review clarified the nature of the Veteran's hypertriglyceridemia. The examiner clarified that the diagnosed familial hypertriglyceridemia is a genetic defect (05/10/2021 C&P Exam, pg. 2). A June 2021 examiner also confirmed the Veteran's hypertriglyceridemia was inherited, and genetic, not resulting from any in-service condition or incident (06/23/2021 C&P Exam, pg. 2). Taking these medical opinions together, the Board concludes that the Veteran's familial hyperglyceridemia is a congenital or developmental defect. As such, service connection is precluded by VA regulation. 38 C.F.R. §§ 3.303(c), 4.9. Whether this defect was subject to superimposed disease or injury, specifically diabetes or pancreatitis, during service is discussed in the sections below. As a separate matter, the Board has considered the Veteran's contention that his familial hypertriglyceridemia has been aggravated by his service-connected major depressive disorder by preventing him from complying with treatment plans causing or aggravating his hypertriglyceridemia. Even if hypertriglyceridemia was not a defect that precludes service connection, the medical evidence of record weighs against the Veteran's contentions. An August 2019 VA examiner addressed the Veteran's contention that his service-connected major depressive disorder has aggravated his hypertriglyceridemia. After an in-person examination and review of the Veteran's claims file, the August 2019 examiner provided a negative nexus opinion, finding that the Veteran's hypertriglyceridemia was not at least as likely as not aggravated beyond its natural progression by his service-connected condition. The examiner explained that mental health disorders, including Veteran's service-connected major depressive disorder, have no direct pathophysiological effects on hypertriglyceridemia, pancreatitis, or diabetes mellitus. Behaviors, including medication non-compliance, poor diet choices, and lack of exercise, that contribute to poor control of hypertriglyceridemia or diabetes mellitus, which can then result in acute pancreatitis episodes, are multi-factorial and not caused by any single condition including major depressive disorder. The examiner concluded the co-existence of major depressive disorder does not by itself result in poor control of or aggravation of hypertriglyceridemia, or pancreatitis, or diabetes mellitus (08/24/2019 C&P Exam, pg. 3). The Board finds the evidence of record weighs against the Veteran's contention that his hypertriglyceridemia is a disease that was caused or aggravated by his service-connected major depressive disorder. Rather, the most probative medical evidence of record suggests the Veteran's hypertriglyceridemia is familial type, inherited, not acquired, and a genetic defect. As a defect, a grant of service connection is precluded as a matter of law. Accordingly, the Veteran's claim for service connection for familial hypertriglyceridemia must be denied. 2. Pancreatitis. 3. Diabetes Mellitus, Type II. The Veteran has claimed entitlement to service connection for diabetes and pancreatitis, to include as a result of familial hypertriglyceridemia and aggravated by his service-connected major depressive disorder. The Veteran's diagnosis with acute pancreatitis was confirmed by a June 2021 VA examination (06/23/2021 C&P Exam). In this regard, the Board notes the diagnosis of chronic pancreatitis was not supported by the evidence (08/24/2019 C&P Exam, pg. 3). The Veteran's diagnosis with diabetes mellitus, type II was confirmed during a June 2019 VA examination (08/24/2019 C&P Exam, pg. 2). Finding the first element of service connection for both disabilities has been met, the questions for the Board are whether the Veteran's currently diagnosed diabetes or pancreatitis was superimposed upon a defect during service or whether either began during service or is at least as likely as not related to an in-service injury, event, or disease. Finally, the Board will address whether the Veteran's diabetes or pancreatitis has been aggravated beyond its normal progression by his service-connected major depressive disorder. Turning to whether either pancreatitis or diabetes is a superimposed disease or injury upon the Veteran's diagnosed defect of familial hypertriglyceridemia, the Board notes the Veteran's service treatment records do not include complaints, treatment for or diagnosis with diabetes mellitus or pancreatitis. In November 1994, the Veteran was clinically evaluated as normal and found qualified for separation (04/20/2014 STR Medical, pgs. 11-12). While not entirely dispositive, the separation physical and service treatment records weigh against a finding of in-service onset of, or superimposed pathology due to disease or injury in-service. A June 2019 VA examination addressed the Veteran's diabetes mellitus, type II (08/24/2019 C&P Exam). The examiner considered the Veteran had an elevated glucose level of 136 at the time of his in-service separation examination. The examiner noted that the records did not specify whether the lab specimens were obtained in a fasting state. A retest of glucose is of record. Upon retest, the level was within normal limits. The June 2019 examiner explained that because the initial specimen to assess the Veteran's glucose level was drawn in an unknown fasting state, and the glucose recheck was normal, no diagnosis of diabetes mellitus was warranted or rendered during service. The examiner also noted the Veteran's glucose level was also normal as in March 1995, indicating no diagnosis of diabetes was warranted months after service. The examiner concluded the evidence did not suggest the Veteran's diabetes had its onset in-service or within one year of service (08/24/2019 C&P Exam). Other post service treatment notes support that the Veteran's diabetes diagnosis was not made for years after service. By way of example, a May 2009 treatment note referenced the Veteran's diabetes diagnosis was made the previous year, that is approximately 2008, over a decade after his active service (10/09/2019 CAPRI, pg. 97). Likewise, the Veteran was not diagnosed with pancreatitis until 2006, also more than a decade after his service (06/23/2021 C&P Exam, pg. 2). The Veteran has been afforded a number of VA examinations, and the record includes associated opinions and record reviews for both diabetes and pancreatitis. Negative nexus opinions were consistently provided (06/23/2021 C&P Exam; 05/10/2021 C&P Exam; 08/24/2019 C&P Exam). Although the May 2021 examiner acknowledged hypertriglyceridemia is a risk factor for pancreatitis and diabetes, the examiner did not find either was a superimposed disease or injury upon the defect of familial hypertriglyceridemia (05/10/2021 C&P Exam, pg. 2). Further, in considering the Veteran's contentions in support of his claims for pancreatitis and diabetes, the June 2021 examiner explained that the record does not support any causative pathophysiology between the hypertriglyceridemia, pancreatitis, and diabetes. The examiner described an association, as opposed to superimposition upon hypertriglyceridemia. The examiner acknowledged while hypertriglyceridemia can result in pancreatitis, which in turn adversely affects the pancreas and leads to diabetes, in the Veteran's case this is not related to service related, but rather his genetics (06/23/2021 C&P Exam, pg. 4). Taken together the Board finds the medical evidence of record weighs against finding the Veteran's diagnosis of diabetes mellitus or pancreatitis began during service or were superimposed upon his hyperglyceridemia during service. Turning to the Veteran's contention that his pancreatitis and diabetes were aggravated beyond natural progression by his major depressive disorder, the Board finds the June 2019 examination to be highly probative (08/24/2019 C&P Exam). After an in-person examination and review of the Veteran's e-folder, the examiner opined the Veteran's diabetes and pancreatitis were not at least as likely as not aggravated beyond their natural progression by service-connected major depressive disorder (06/28/2021 Rating Decision - Codesheet). The examiner considered the Veteran's service-connected disabilities of bilateral plantar fasciitis, osteoarthritis of spine, bilateral lower extremity sciatic radiculopathy, finding they are unrelated to and not causative for or affecting pancreatitis, or diabetes mellitus. The examiner explained those service-connected conditions have no relationship to hypertriglyceridemia, or pancreatitis, or diabetes mellitus, the course and progression of hypertriglyceridemia, or pancreatitis, or diabetes mellitus cannot be aggravated by or otherwise affected by them. The examiner explained that mental health disorders, including Veteran's service-connected major depressive disorder, have no direct pathophysiological effects on pancreatitis or diabetes mellitus. Major depressive disorder is a disorder with no clinical relationship to pancreatitis or diabetes mellitus. The examiners emphasized that behaviors, including medication non-compliance, poor diet choices, and lack of exercise, that contribute to poor control of hypertriglyceridemia or diabetes mellitus, which can then result in acute pancreatitis episodes, are multi-factorial and not caused by any single condition, including major depressive disorder. To clarify, the examiner provided the coexistence with major depressive disorder does not by itself result in poor control of, or aggravation of, pancreatitis or diabetes mellitus. (08/24/2019 C&P Exam, pg. 3). The Board has considered that the Veteran believes his pancreatitis and diabetes mellitus are related to an in-service injury, event, or disease, was superimposed upon his familial hypertriglyceridemia, or was aggravated by his service-connected major depressive disorder. The evidence of record does not suggest the Veteran has specialized training or medical knowledge making him competent to provide diagnoses or nexus opinions regarding his theories of entitlement for diabetes or pancreatitis. These issues are medically complex, requiring knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Finding the matters to be outside the competence of the Veteran, the Board cannot assign his lay statements probative weight as to diagnoses or nexus. Consequently, the Board assigns more probative values to the medical evidence of record described previously. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). The Board has also considered the articles of record (02/01/2016 Correspondence). The June 2019 examiner considered the Veteran's contentions and articles of record, and aside from acknowledging that one of the two articles indicated hypertriglyceridemia can and does develop secondary to uncontrolled Type II diabetes mellitus, the examiner did not find the articles were applicable in the Veteran's case (08/24/2019 C&P Exam, pg. 3). The Board finds the articles to be of little relevance as they primarily focus on an association between hypertriglyceridemia and coronary heart disease, as opposed to diabetes or pancreatitis. The Board finds the collective medical examinations and accompanying opinions to be the most probative evidence of record. When considered together, they thoroughly address the Veteran's contentions and asserted theories of entitlement to service connection. The opinions are grounded in an understanding of the defect and diseases at issue, and an accurate account of the Veteran's medical history, and often include references to medical literature. For these reasons, the Board finds the opinions highly probative, weighing against the Veteran's claims. The Board acknowledges that diabetes mellitus is a chronic disease listed under 38 C.F.R. § 3.309(a). As discussed above, probative medical evidence of record does not suggest that his diabetes was diagnosed in service, or within one year of service warranting service connection. The most probative evidence suggests the diabetes diagnosis was made more than a decade after the Veteran was separated from service. Accordingly, the Board does not find a grant of service connection pursuant to 38 C.F.R. § 3.307 is warranted in this case. In reviewing this claim, the Board has considered whether additional remand is required. The Board concludes that further remand will not assist the Board with review of evidence of record, and to remand this claim for further development would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran, which is to be avoided. Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); 38 U.S.C. § 7261(b). In light of the foregoing, the Board concludes that the weight of the most probative evidence of record is against finding that the Veteran's diagnoses of diabetes mellitus or pancreatitis began during service, are otherwise related to an in-service injury, event, or disease, were superimposed upon his hyperglyceridemia during service, or were aggravated by his major depressive disorder. Accordingly, the Veteran's claims of service connection for pancreatitis and diabetes mellitus are denied. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. A. Myers 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.