Citation Nr: 21076264 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 18-45 751 DATE: December 22, 2021 ORDER Service connection for diabetes mellitus type II, including as due to herbicide exposure, is granted. Service connection for erectile dysfunction, including as due to service-connected diabetes mellitus type II, is granted. FINDINGS OF FACT 1. The Veteran has a current disability of diabetes mellitus type II. 2. The Veteran served in the Republic of Vietnam (Vietnam) from April 1967 to April 1968; the Veteran is presumed to have been exposed to herbicide agents while stationed in Vietnam. 3. The Veteran has a current disability of erectile dysfunction. 4. As of this decision, the Veteran is service connected for diabetes mellitus type II. 5. The erectile dysfunction is causally connected to the service-connected diabetes mellitus type II. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for diabetes mellitus type II have been met. 38 U.S.C. §§ 1110, 1112, 1154, 5103, 5013A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 2. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for erectile dysfunction, as secondary to the service-connected diabetes mellitus, have been met. 38 U.S.C. §§ 1110, 1154, 5103, 5013A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army during the Vietnam Era from November 1965 to November 1968. The Veteran initially claimed service connection for the diabetes and the erectile dysfunction in October 2014. Both claims were denied in a March 2015 Rating Decision. The Veteran filed a Notice of Disagreement in January 2016, and a Statement of the Case was issued in September 2018. The Veteran filed a Form 9 in September 2018, and requested a hearing before the Board. A hearing was held before the below-signed judge in August 2020. In October 2020, the Board remanded the issues of service connection for diabetes and erectile dysfunction for the Agency of Original Jurisdiction (AOJ) to obtain an examination to determine whether the Veteran has a current disability of diabetes. The AOJ has fulfilled its obligations under the remand instructions. 1. Service connection for diabetes mellitus type II is granted. Service connection may be granted on a presumptive basis for certain diseases associated with exposure to certain herbicide agents, even though there is no record of such disease during service, if they manifest to a compensable degree any time after service, in a veteran who had active military, naval, or air service for at least 90 days, during the period beginning on January 9, 1962 and ending on May 7, 1975, in the Republic of Vietnam, including the waters offshore, and other locations if the conditions of service involved duty or visitation in Vietnam. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309(e), 3.313. This presumption may be rebutted by affirmative evidence to the contrary. 38 U.S.C. § 1113; 38 C.F.R. §§ 3.307, 3.309. Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes) is deemed associated with herbicide exposure. 38 C.F.R. § 3.309(e). As such, diabetes mellitus type II is a disease for which presumptive service connection based on exposure to herbicides may be granted. Notwithstanding the foregoing presumption provisions for herbicide exposure, a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); see also Ramey v. Gober, 120 F.3d 1239, 1247-48 (Fed. Cir. 1997), aff 'g Ramey v. Brown, 9 Vet. App. 40 (1996); Brock v. Brown, 10 Vet. App. 155, 160-61 (1997). The Veteran asserts that presumptive service connection for diabetes mellitus type II is warranted due to exposure to herbicides during service when stationed in the Republic of Vietnam. See August 2020 Board Hearing Transcript. The Board finds that the Veteran served in the Republic of Vietnam (Vietnam) from April 1967 to April 1968; the Veteran is presumed to have been exposed to herbicide agents while stationed in Vietnam. The evidence shows a current disability of diabetes mellitus type II. A VA examination performed in April 2020 diagnosed diabetes mellitus type II. The diagnosis was made on the basis of two readings of the A1C (average blood sugar) levels above 6.5%. Resolving reasonable doubt in the Veteran's favor, the Board finds that the criteria for presumptive service connection for diabetes mellitus type II have been met. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. As presumptive service connection is being granted, there is no need to discuss entitlement to service connection on a direct or any other basis, as other theories of service connection have been rendered moot, leaving no question of law or fact to decide. See 38 U.S.C. § 7104. 2. Service connection for erectile dysfunction Service connection may be granted for a disability that is proximately due to or the result of a service-connected disability. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310(a).; Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or the result of, a service-connected disease or injury. To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). The Veteran contends that the erectile dysfunction is caused by the service-connected diabetes mellitus type II. See October 2014 Claim for Compensation. The evidence shows a current disability of erectile dysfunction. The Veteran has been treated for erectile dysfunction since around 2008, with a confirmed diagnosis in January 2015. See January 2015 VA Examination. The diagnosis of diabetes was made on the basis of two readings of the A1C (average blood sugar) levels above 6.5%. The CDC defines diabetes as having A1C levels above 6.4%, "prediabetes" as having A1C levels between 5.7% and 6.4%, and normal blood sugar levels when A1C levels are below 5.7%. Prediabetes is a condition marked by elevated levels of blood sugar that often progresses to type II diabetes. Merriam-Webster's Medical Dictionary, "Prediabetes." The record shows A1C levels commensurate with prediabetes since at least 2004. VA treatment records show that A1C levels at 5.9% in November 2004. A January 2015 VA examination showed A1C levels at 6.2%. Since 2004, VA treatment records show the Veteran being counselled on healthy behaviors to ameliorate the possibility of the prediabetes progressing to type II diabetes. After weighing the evidence, lay and medical, the Board finds that the evidence is at least in relative equipoise on the question of whether the erectile dysfunction is causally connected to the service-connected diabetes mellitus type II. A January 2015 VA examination diagnosed erectile dysfunction, but noted that the Veteran had reported an onset six years prior (approximately 2008). The 2015 examiner opined that it was less likely than not that the erectile dysfunction was due to the diabetes, as at the time the Veteran did not meet the criteria for diabetes, and the erectile dysfunction did not worsen as the A1C levels increased over time. The Board finds this opinion to be based on an incorrect factual assumption. The A1C levels were in prediabetic levels before the erectile dysfunction appeared (2004 and 2008, respectively); therefore, the erectile dysfunction would not have been expected to worsen, as A1C levels were already high, not rising. An April 2021 VA examination addendum assumed that the erectile dysfunction predated the diagnosis of diabetes, and from that assumption reasoned so there is no causal link between the two disorders, but reasoned that the diabetes was steroid induced in 2020. This purported opinion is not based on accurate factual assumptions as it ignores the fact that (as noted by the treatment for prediabetes) the Veteran was already experiencing elevated A1C levels prior to the claimed onset of erectile dysfunction. Prior to the addendum, the April 2021 examiner opined that the erectile dysfunction was more likely than not caused by the diabetes. The VA examiner noted that diabetes can damage the blood supply to the penis and the nerves that control the erection. As diabetes is caused by elevated A1C levels, and accordingly the symptoms of diabetes are due to elevated A1C levels, then logically the rising A1C levels (that are characterized as "prediabetes") had similar damaging effects on the blood supply and the nerves that only worsened as the A1C levels reached diabetes type II levels. The Board thus concludes that the erectile dysfunction is causally connected to the diabetes type II. Resolving reasonable doubt in the Veteran's favor, the Board finds that the criteria for secondary service connection for erectile dysfunction have been met. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. J. PARKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Charles Plambeck 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.