Citation Nr: 21075220 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 16-40 329 DATE: December 17, 2021 ORDER Entitlement to service connection for diabetes, claimed as blackouts, fainting, and tiredness, is denied. Entitlement to service connection for peripheral vascular disease, to include peripheral artery disease, claimed as hip to feet burning sensation, is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that diabetes began during active service, or is otherwise related to an in-service event, injury, or disease. 2. The preponderance of the evidence is against finding that peripheral vascular disease began during active service, or is otherwise related to an in-service event, injury, or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for diabetes are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for peripheral vascular disease are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active-duty service in the United States Army from July to November 1976. In May 2018, the Veteran had a hearing before the undersigned Veterans Law Judge on the issues decided herein. For the claim for service connection for an acquired psychiatric disorder, that matter arose separately from those issues. The Veteran withdrew his request for a hearing on an acquired psychiatric disorder in December 2019. In November 2018, the Board remanded the issues for service connection for diabetes mellitus and for peripheral vascular disease to allow evidence to be associated with the claims file. In August 2020, those matters, as well as the separately appealed acquired psychiatric disorder matter were remanded by the Board of Veterans' Appeals (Board) to allow for additional development, specifically for VA examinations. Service Connection 1. Entitlement to service connection for diabetes, claimed as blackouts, fainting, and tiredness. The Veteran contends that his diabetes started during service (July to November 1976). He currently claims that he has had symptoms such as blackouts, fainting, and tiredness since that time, which he relates to his diabetes. 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). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that although the Veteran has a current diagnosis of diabetes, the preponderance of the evidence weighs against finding that it began during service or is otherwise related to an in-service injury, event, or disease. No medical evidence of record indicates that the Veteran was diagnosed with diabetes in service or for decades after service. In a March 2018 correspondence, the Veteran claimed he was not diagnosed in service because he was discharged early "due to having continuous fainting spells and lightheadedness" and never given the opportunity to go to sick call but would sit out of training. He further referenced an October 1976 in-service optometric evaluation wherein the provider indicated that the Veteran was in good health. The Veteran claims that he had told that examiner what he was experiencing and was not assessed. The Board finds that the Veteran is not credible in his claim that he was discharged early due to having continuous fainting spells and lightheadedness. In an October 1976 service personnel record regarding his proposed discharge, his Commanding Officer reported that he recommended discharge because the Veteran had been counseled on his unwillingness to follow instructions and indifference toward his commitment to the Army. He was counseled on his resentment on discipline and your poor attitude. He was also transferred to another platoon in an attempt to improve his attitude and performance, but his new Platoon Sergeant found continued indifference to his responsibilities and continuing disciplinary action. The Commanding Officer found that the Veteran's "poor attitude...a liability to any unit...in the future. For these reasons I am recommending your discharge from the U.S. Army." An October 1976 service counseling record similarly indicated that discharge was recommended due to the Veteran being "filled with hostility and resentment against all authority" and reportedly the Veteran just wanted out of service. The Board finds the contemporaneous reports regarding the cause of the Veteran's discharge to be more credible that the Veteran's current claims. Also, to the extent that the Veteran claims that he never had the opportunity to go to sick call, the Board finds that contention not credible as there are multiple service treatment records of the Veteran seeking and receiving treatment for other complaints unrelated to fainting spells, tiredness, or lightheadedness. Moreover, in his October 1976 proposed discharge action, the Veteran specifically indicated that he did not want a separation medical examination if his discharge was approved. Furthermore, to the extent that the Veteran has claimed that his symptoms have been a chronic problem since service, the Board notes that the contemporaneous post-service treatment records do not indicate continuous complaints of blackouts, fainting, tiredness. Rather, his reports of past medical history in private medical records do not indicate any such complaints, including in a September 2000 Parkview Regional Hospital history and physical, January 2002 letter from Dr. J.B.B., and a January 2014 VA primary care history and physical to establish VA care. The earliest reference of a diagnosis of diabetes by the Veteran's medical providers is in the mid-1990s, close to twenty years after the Veteran's 1976 separation from service. For example, a March 2007 Providence Hospital record documented a past medical history of diabetes since 1995. The Board finds that the Veteran's diabetes was not diagnosed until well over a decade after his separation from service. As such, service connection on a presumptive basis is not warranted. 38 C.F.R. § 3.309(a). The Board further notes that VA and private medical records generally document treatment for diabetes, but generally do not provide medical opinions as to the etiology of his diabetes. At most, a May 2018 letter from Dr. D.C.A. noted that the Veteran believed his symptoms in service and emotional stress caused his diabetes. Dr. A. noted that he "told him that all of that makes sense from a medical standpoint but, of course, I have no data or information to confirm his suspicions." Even though the Veteran is competent to report having experienced symptoms to include blackouts, fainting, and tiredness since service, he is not competent to provide a diagnosis of diabetes in this case or determine that these symptoms were manifestations of diabetes. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Indeed, as a matter of general knowledge, blood tests are generally required to form a diagnosis diabetes. The November 2020 VA examiner similarly noted that although there are medical reports of diabetes diagnosed in 1995, labs from that time are unavailable and there are no documents prior to 2007 referencing high or low glucose levels, as such, diabetes could not be confirmed without labs. A diagnosis or etiology 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. Jandreau, supra.; see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). In a September 2021 lay statement, the Veteran further claimed that his endocrinologist had previously indicated that it was possible that he was pre-diabetic for an extended time. He made a similar claim in a July 2019 lay statement. In this regard, a lay person's account of what a doctor purportedly said is too attenuated and inherently unreliable to constitute "medical" evidence. Robinette v. Brown, 8 Vet. App. 69, 77 (1995) (Veteran's statement that his physician told him that he "most probably" had diabetes at time of his discharge from service was not sufficient medical evidence to establish service connection for diabetes). Further, the November 2020 VA examiner opined that the Veteran's diabetes is not at least as likely as not related to an in-service injury, event, or disease, including claimed symptoms in service. The VA examiner explained that the Veteran was never diagnosed during his approximately five months of military service. As further noted in the VA examination, the VA examiner further explained that the earliest record reporting diabetes indicated a diagnosis in 1995, that such a diagnosis could not be verified until over a decade later. In addition, he considered the Veteran's claim that stress in service caused his diabetes. The examiner noted that major risk factors for diabetes included factors such as age (over 45 yrs), ethnicity (African American being one risk factor), high blood pressure, family history of diabetes, not being physically active, and having heart disease. The examiner further explained that there was no evidence that the Veteran had or developed diabetes mellitus during his five months of service. Rather, diabetes mellitus is a condition that takes years to develop. It is typically resulting from poor lifestyle choices such as diet, inactivity, and excess weight none of which are promoted while in the service. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board finds that the May 2018 letter from Dr. D.C.A. is less probative than the VA examiner's opinion. There is no indication that that private doctor physically examined the Veteran or reviewed pertinent medical evidence in the claims file. Instead, the opinion appears to be based on inaccurate information and the Veteran's self-reported medical history, which has been refuted by contemporaneous evidence, such as the service personnel and treatment records discussed above. Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). Consequently, the Board gives more probative weight to the November 2020 VA examiner's opinion. As the preponderance of the most probative evidence is against the claim, the benefit of the doubt rule does not apply. Service connection for diabetes is denied. 2. Entitlement to service connection for peripheral vascular disease, claimed as hip to feet burning sensation. The Veteran asserts that he has had symptoms of peripheral vascular disease since service. 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 question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. A June 2007 private medical record from Providence Hospital indicated that in March 2007 the Veteran was diagnosed with peripheral vascular occlusive disease and underwent a saphenous vein graft. In a March 2018 correspondence, the Veteran claimed that his peripheral vascular disease was attributed to the onset of diabetes and that he distinctly remembered having severe problems completing marches and physical training to the point he was ordered to "sit it out." He further claimed that he was given an honorable discharge because he was experiencing these issues causing the Company Commander to recommend discharge. In a September 2021 correspondence, he reported that regarding his peripheral vascular disease, he had pain and discomfort during road marches and physical training, but not in high school track. As noted in more detail in the above decision, the Veteran's reports as to why he was discharged are not consistent with the more probative contemporaneous reports of the cause of discharge. For example, in an October 1976 service personnel record regarding his proposed discharge, his Commanding Officer found that the Veteran's "poor attitude...a liability to any unit...in the future. For these reasons I am recommending your discharge from the U.S. Army." In an October 1976 service counseling record, his superior officer similarly recommended discharge due to the Veteran being "filled with hostility and resentment against all authority" and that the Veteran just wanted out of service. The Board finds the contemporaneous reports regarding the cause of the Veteran's discharge to be more credible that the Veteran's current claims. To the extent that the Veteran may be claiming he did not have the opportunity to go to sick call for his leg pain, the Board finds that contention not credible as there are multiple service treatment records of the Veteran seeking and receiving treatment for other complaints. Indeed, in one October 1976 service treatment record, the Veteran denied any tingling or numbness of the buttock or leg and decreased foot sense. In his October 1976 proposed discharge action, the Veteran specifically declined a separation medical examination if his discharge was approved. To the extent that the Veteran has claimed that his lower extremity symptoms have been a chronic problem since service, contemporaneous post-service treatment records do not support such a contention. As noted in a March 2018 letter from the Veteran, his peripheral artery disease was "acquired in 2007." He further reported problems with his legs while working in the 1980s after service due to "severe problems with my legs," including difficulty getting in and out of the delivery truck and the fast-paced environment of his job duties with the postal service. In contrast, a January 2002 evaluation from Dr. J.B.B. indicated that the Veteran complained of two contentions "diabetes mellitus and feet swelling" and pain in arms, indicating that the feet swelling was associated with the diabetes. He further indicated the Veteran was able to walk about two to three miles at a time, though his feet would swell at times from standing. At that time, about 5 years prior to the Veteran having acquired a peripheral vascular disease, that physician found no evidence of deep venous insufficiency, though the examiner did note a history of vague foot pain. The examiner found "[n]o evidence of...peripheral vascular system...due to diabetes mellitus" and "[n]o significant reproducible fatigue in motor function with substantial motor weakness on repetitive activity during exam." Similarly, in a June 2003 private medical record, from Providence Hospital, the Veteran complained of shortness of breath and edema in the lower extremities for three weeks. The examiner found that the Veteran had new onset congestive heart failure/cardiomyopathy. No peripheral vascular disease was indicated at that time. No cyanosis, clubbing, or edema of the extremities was found. The Board notes that the Veteran did not report a claimed chronicity of complaints regarding the lower extremities since the 1970s at either time, despite specifically being evaluated regarding his vague foot complaints or lower extremity complaints. An April 2007 private medical record from the Hillcrest Health System noted a complaint of leg pain, first diagnosed one week ago. As noted above, the Veteran has reported that his peripheral vascular disease was acquired in 2007, decades after service. In a May 2014 VA medical record, the Veteran reported that his chief complaint remained his bilateral leg pains, which had been present for years and with onset of his peripheral vascular disease issues. This report is consistent with the Veteran's report of leg pain beginning in 2007, per the April 2007 record. The Board finds this contemporaneous evidence to be more probative as to the possible chronicity of complaints since service over that the Veteran's current claims of chronicity since service. Although the Veteran is competent to report having experienced symptoms of leg pain in service, given the above evidence the Board does not find that such reports of pain or chronicity to be credible. Furthermore, he is not competent to provide a diagnosis in this case or determine that any symptoms were manifestations of peripheral vascular disease. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body. The record does not indicate that the Veteran has the medical training or credentials to make a determination as to diagnosis or etiology. In contrast, physicians evaluating the Veteran specifically for complaints regarding the lower extremities decades after his separation from service did not diagnose the Veteran for peripheral vascular disease for years. Although VA and private medical records generally document treatment for peripheral vascular disease, they do not provide medical opinions as to the etiology of the claimed disorder. The only medical professional to address that question is the November 2020 VA examiner. The November 2020 VA examiner noted the Veteran's complaint of burning pain in his bilateral feet and legs after marching in basic training, but opined that the Veteran's peripheral vascular disease was not at least as likely as not related to an in-service injury, event, or disease, and did not develop during service. He explained that peripheral vascular disease takes years to develop and is not the result of five months of anything. As such, the examiner found that one cannot conclude that there was any acute peripheral vascular disease in the Veteran's five months in service. Rather, there are numerous reasons for pain in one's feet and legs after marching, most of which have nothing to do with any acute or chronic disease. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). To the extent that the Veteran has claimed to have peripheral vascular disease that was caused or aggravated by his diabetes, the Board notes that as service connection for diabetes has been denied, service connection secondary to diabetes is not possible. 38 C.F.R. § 3.310. As the preponderance of the most probative evidence is against the claim, the benefit of the doubt rule does not apply. Service connection for peripheral vascular disease is denied. REASONS FOR REMAND 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. In a June 2017 lay statement, the Veteran claimed that his acquired psychiatric disorder began during service, though he was traumatized prior to service when he witnessed his friend die. This matter was previously remanded for a VA examination, which was obtained in August 2021. In a September 2021 correspondence the Veteran claimed that the VA examination was inadequate as it focused on his current struggles in the last three years while his claim has been going on for longer than that time. The Board finds that an addendum VA medical opinion is necessary. The August 2021 VA examination report was confusing in not addressing prior diagnoses and noting a diagnosis of adjustment disorder in only the comments section, but not the diagnosis section. The only diagnosis noted in the diagnosis section was PTSD, which the examiner related to recent events. He did not address the VA medical records documenting various diagnoses, including a mood disorder due to medical condition in March 2007, a depressive disorder in October 2016, and PTSD in May 2017 (by a graduate psychologist). Also, as noted by the Veteran, he has claimed to have a psychiatric disorder even prior to the recent events noted by the examiner, which should be addressed. Any unassociated VA medical records should be obtained. The matters are REMANDED for the following actions: 1. Associate any unassociated VA medical records with the claims file. 2. After the above record development is accomplished, obtain an addendum medical opinion for the acquired psychiatric disorder. Only if deemed necessary by the VA medical opinion provider, should a new VA examination be obtained to determine the nature and etiology of any acquired psychiatric disorder, to include PTSD. If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. Currently, the Veteran claims to have PTSD due to a pre-service stressor of witnessing his friend die (see June 2017 lay statement and April 2018 NOD). If any other acquired psychiatric disorders are diagnosed, the examiner must opine whether EACH diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease. To the extent possible, the examiner should reconcile his/her findings with prior diagnoses, such as for mood disorder due to medical condition in a March 2007 VA medical record, a depressive disorder in an October 2016 VA medical record, and PTSD in a in May 2017 VA medical record. The full claims file should be reviewed, to include lay evidence, prior VA examinations, VA medical records, service personnel records, and private medical records (such as records from the Diabetes and Endocrine Center). A fully articulated medical rationale for any opinion expressed must be set forth in the medical report. The VA medical opinion provider should discuss the particulars of this Veteran's medical history and relevant medical science as applicable to this case, which may reasonably explain the medical guidance in the study of this case. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Lindio 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.