Citation Nr: 21069557 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 11-31 768 DATE: November 18, 2021 ORDER Service connection for diabetes mellitus, type II is denied. FINDING OF FACT The Veteran's diabetes mellitus, type II was first shown many years after active service and therefore did not begin during service and is not otherwise related to an in-service injury or disease or aggravated by his service-connected disability. CONCLUSION OF LAW The criteria for service connection for diabetes mellitus, type II, are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from June 1966 to May 1969 and in the Air Force from November 1990 to July 1991 with additional service in the Reserves. The matter was originally before the Board of Veterans' Appeals (Board) on appeal from a May 2009 rating decision of the Agency of Original Jurisdiction (AOJ). In a July 2019 decision, the Board issued a decision which denied service connection for a low back disorder and diabetes mellitus, type II. In December 2020, the Veteran appealed the July 2019 Board decision to the United States Court of Appeals for Veterans Claims (Court) where the Court granted a Joint Motion for Remand (Joint Motion). The Court's Order vacated the Board's July 2019 decision and remanded the matter to the Board for consideration consistent with the terms of the joint motion. The Board remanded the matter in June 2021 for additional development. While on remand, in a September 2021 rating decision, the AOJ granted service connection for low back disorder. The Board finds the AOJ's decision for this issue constitutes a full award of the benefits sought on appeal. Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). Thus, the Board has no jurisdiction to review the certified issue, and the claim is no longer in appellate status. The remaining issue, addressed herein, returned to the Board for appellate review. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (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. 38 C.F.R. § 3.310(a). Entitlement to service connection for diabetes mellitus, type II. The Veteran contends that he had presence of diabetes during service and that his current diagnosis is etiologically related to service. Alternatively, the Veteran claims his diabetes is related to his service-connected PTSD. See Appellant Brief dated June 2019. While the record shows a current diagnoses of diabetes mellitus, type II, the Board concludes that the preponderance of the evidence weighs against finding that the Veteran's diagnosis began during service or is otherwise related to an in-service injury, event, or disease or aggravated by his service-connected posttraumatic stress disorder (PTSD). The Veteran's service treatment records are negative for treatment or findings of prediabetes or diabetes. He had normal clinical findings on his separation physical of May 1991. The Veteran's post-service medical records show elevated glucose levels in February and March 1992, September 1993 with findings of borderline diabetes starting from November 1993. A formal diagnosis of diabetes mellitus, type II, was not established until August 1999. As to the theory of direct service connection, the Board finds highly probative the objective medical evidence of record including an October 2016 VA medical opinion, July and September 2021 VA contract opinion of record. The record shows an October 2016 VA physician finding the claimed diabetes mellitus less likely than not incurred in or caused by service. In support of this conclusion, the VA physician indicated "that a diagnosis of glucose intolerance (based on findings of a fasting blood glucose level) "was established on 12/25/1995, at a time where [the veteran] was already separated from the reserves." The VA physician noted that "blood glucose levels were not always elevated during that time, and were for the most part mildly elevated, not reaching the diabetic range." The VA physician added "glucose intolerance is not synonymous of DM and can be revered with lifestyle modifications as were suggest to him at that time." See VA examination and medical opinion of October 2016. The VA physician pointed out that the Veteran was followed by a primary treating physician Dr. S. during all this time and he established the diagnosis of "Diet controlled DM in 9/2000". The VA physician added that Dr. S. "wrote a letter on 10/27/2008, stating that a diagnosis of DM was NOT present during hi service in desert storm." Based on the evidence reviewed, the October 2016 VA physician opined that the Veteran's DM is less likely incurred during "service from 1966 to 1969, during period of activation from 1990 to 1991, nor during period from 1991 to 1995. A diagnosis of DM was first established in 1999." Id. The record shows a July 2021 VA contract opinion where the examiner determined the Veteran's claimed diabetes mellitus was less likely than not incurred in or caused by in-service injury, event, or illness. In the rationale, the examiner found the veteran's service treatment records from 1966 to 1969 negative for diabetes complaints, treatment or diagnosis, and found no evidence of a diabetic condition in service. The examiner added the veteran was "first noted to have elevated blood glucose in November 1993 and June 1994 and diagnosed with borderline diabetes. This was not a chronic condition. The Veteran had occasional elevated blood glucose levels, but they were not consistent" and not diagnosed in service or within a year of service. The examiner pointed out the veteran was "diagnosed with diabetes in 8/1999. The veteran did not have chronic condition in service and it did not develop to a compensable level within a year of service, therefore it is less likely than not." See July 2021 Medical opinion Disability Benefits Questionnaire (DBQ). The record shows an addendum opinion was obtained in September 2021 rendered by the same examiner above. In addressing the statements from the Veteran's treating physician, the examiner stated, "a letter dated 10/27/2008 the veteran's provider [D.S., M.D.] notes an elevated blood sugar... and concludes that he does not have objective numbers to say he definitely had diabetes at that time." The examiner added, "a letter dated 11/11/2008 [D.S., M.D.] states that it is at least as likely as not that the veteran's diabetes developed while on active duty but that it did not manifest itself until several years later." The examiner pointed out that the Veteran's treating physician "does not discuss how the veteran's diabetes developed on active duty but that it did not manifest until 1999." The examiner noted elevated blood glucose in November 1993 and June 1994 and findings of borderline diabetes but commented that "this was not a chronic condition. The veteran had occasional elevated blood glucose levels, but they were not consistent or chronic and they were not diagnosed as diabetes in service or within a year of service. The veteran was diagnosed with diabetes in 8/1999. The veteran did not have chronic condition in service and it did not develop to a compensable level within a year of service, therefore, it is less likely than not." See September 2021 Addendum VA contract opinion. The Board acknowledges the October and November 2008 letters from the Veteran's treating physician, D.S., M.D., who submitted brief statements in support of the Veteran's claim. In the October 2008 statement, the Veteran's treating physician indicated his limited review of "only two" sugar readings from 1990 and 1992, and based on that review the Veteran "certainly could have had insulin resistance in a prediabetic condition during that time" but added that he does not "have any objective numbers to say he definitely had diabetes during that time." See Statement from D.S., M.D. dated October 2008. In a similar November 2008 statement, the same treating physician submitted a brief three sentence letter indicating that the Veteran was "a long time patient" and the Veteran served in desert storm one. The physician opined it is as likely as not that the Veteran's diabetes developed while on active duty, "although, he did not have an immediate manifestation until he came back several years later." See Statement from D.S., M.D. dated November 2008. However, the Board finds treating physician's brief statements carries less probative value as it is unclear whether the physician had access to the entire electronic claims file as he presents no supporting rationale for such conclusory statements. Prejean v. West, 13 Vet. App. 444 (2000). In fact, the Veteran's physician acknowledges his opinion is based on review of "only two" glucose readings in 1990 and 1992. Further, the physician presents no supporting rationale for stating how the Veteran "could" be prediabetic during active service and how the physician himself who treated the Veteran since 1985 did not render a diagnosis of "Diet controlled DM" until September 2000. Further, the physician's October 2018 statement is prefaced with "could," which is speculative and inconclusive in nature. Bloom v. West, 12 Vet. App. 185 (1999) (holding that a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). Consequently, the Board assigns significantly less probative value to the October and November 2008 statements from the Veteran's treating physician. Accordingly, the preponderance of the evidence is against the Veteran's claim for service connection for diabetes mellitus, type II on a direct basis, as there is no competent evidence showing a causal connection between diabetes mellitus, type II, and an in-service incurrence. As to presumptive service connection based on chronic disease, as discussed above, there is no persuasive evidence of record that shows a diagnosis of diabetes mellitus type II within one year of separation from the service or that symptoms of the diseases manifested to a compensable degree within a year of his discharge from service. See 38 C.F.R. §§ 3.303(b), 3.309. Regarding the theory of secondary service connection, the Board relies on the June 2018 VA medical opinion. The VA physician opined that "it is less likely than not that the veteran's PTSD caused or aggravated his diabetes mellitus." In the rationale, the VA physician noted there was no diagnosis during active duty time and no line-of-duty determination for diabetes for active time while in the reserves. Specifically, the VA physician noted review of the studies submitted by the Veteran but commented that "Both articles note that although there appears to be an association, no causality was established." Notably, the VA physician pointed out concerns within both articles "include the use of self-reporting the PTSD diagnosis rather than having a clinical diagnosis." Further, the VA physician indicated that "Both articles emphasize the need for continued study of this issue. Neither article describe causality between PTSD and diabetes mellitus type 2." See VA examination dated June 2018. There is no medical opinion to the contrary. Lastly, while the Veteran is competent to report symptoms observable to a layperson, to the extent that he seeks to establish a nexus between a current disability and service or service-connected PTSD, the Board finds lay witnesses are not competent to opine on such medical questions of etiology as this requires medical expertise and the ability to interpret diagnostic medical testing. Davidson v. Shinseki, 581 F.3d 1313 (2009). Accordingly, the Veteran's assertions do not constitute competent medical evidence. Moreover, the probative value of the VA examiner's opinions outweighs that of the Veteran, given the absence of any indication of diabetes mellitus, type II until many years after service, and as the examiner has more education, experience and training in determining the etiology of diabetes mellitus, type II. Based on a review of the foregoing evidence and the applicable laws and regulations, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for diabetes mellitus, type II. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claims, that doctrine is not helpful to this claimant. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. A., 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.