Citation Nr: 21006518 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 18-22 609 DATE: February 4, 2021 ORDER Entitlement to service connection for type 2 diabetes mellitus is denied. FINDINGS OF FACT 1. Type 2 diabetes mellitus was not first manifested on active duty or within the first post-service year, and is not otherwise shown to be related to service. 2. The Veteran’s type 2 diabetes mellitus is unrelated to service-connected obstructive sleep apnea with asthma and medication use. CONCLUSION OF LAW The criteria for service connection for type 2 diabetes mellitus are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty in the U.S. Army from October 1991 to October 2002 and from October 2002 to December 2012. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a November 2016 rating decision by a Regional Office (RO) of the United States Department of Veterans Affairs (VA). In December 2018, the Board remanded this matter for further evidentiary development. Upon return of the appeal in March 2020, the Board again remanded this matter for further evidentiary development. The VA medical opinion having been provided, the directives have been substantially complied with and the matter again are before the Board. D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). In order to establish service connection on a direct basis, the record must contain competent evidence of: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Some chronic diseases may be presumed to have been incurred in service, if they become manifest to a degree of ten percent or more within the applicable presumptive period. 38 U.S.C. §§ 1101(3), 1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a).  For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013).  Diabetes mellitus is a listed condition, with a presumptive condition of one year following separation from service.  Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). See also Bostain v. West, 11 Vet. App. 124, 127 (1998). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. The Veteran contends that he is entitled to service connection for type 2 diabetes mellitus. The Veteran directs attention to elevated glucose levels in service and argues that his diabetes mellitus was present during active service. Alternatively, the Veteran also contends that his prescribed prednisone for his service-connected obstructive sleep apnea with asthma led to his diagnosis of type 2 diabetes mellitus. Service treatment records reflect that the Veteran underwent diagnostic laboratory testing on January 2, 1990; January 7, 2011; and February 3, 2012; which yielded glucose levels of 101 mg/dL, 109 mg/dL, and 127 mg/dL, respectively. Test findings dated January 13, 2011, and February 13, 2012, indicate that the Veteran had a hemoglobin A1c level of 5.3 percent. The Board notes that in February 2012, the Veteran was diagnosed with hyperglycemia. Post-service VA records reflect that the Veteran had a glucose level of 96 mg/dL in May 2013, which was assessed to be within the normal range. Thereafter, subsequent records indicate that the Veteran was diagnosed with type 2 diabetes mellitus in August 2015. The evidence of record reflects that the Veteran’s treating endocrinologist submitted a letter on behalf of the Veteran, dated July 2018. The endocrinologist indicated that while the Veteran was officially diagnosed with diabetes in 2015, a review of the Veteran’s service treatment records indicated that a February 2012 complete metabolic profile showed a glucose level of 127 mg/dL. The endocrinologist noted that the Veteran was fasting at the time per the Veteran’s self-report. The letter stated that the American Diabetes Association considers a diagnosis of diabetes to be a fasting blood sugar level above 126 mg/dL, albeit on two separate occasions. The endocrinologist acknowledged that the Veteran separated from service shortly thereafter and no additional laboratory testing was performed prior to discharge. Nevertheless, endocrinologist reported that it “is generally considered” that one has had type 2 diabetes mellitus for at least five years prior to the actual diagnosis, and as such opined that it is at least as likely as not that the Veteran had diabetes while serving in the military. The Veteran was afforded a VA examination in October 2019. The examination report referenced the August 2015 diagnosis of type 2 diabetes mellitus. The VA examiner opined that based upon a review of the Veteran’s claims file, to include service and post-service treatment records and the July 2018 endocrinologist letter, the Veteran’s diagnosis of type 2 diabetes mellitus is less likely as not related to any of the glucose (blood sugar) or hemoglobin A1c readings noted in active service. The VA examiner indicated that the Veteran was diagnosed with type 2 diabetes mellitus approximately three years after separation from active service, which was at least as likely as not based on a random glucose level of greater than 200 mg/dL which met the diagnostic criteria. The VA examiner further stated that fasting glucose levels noted on at least three different occasions while in service were less than 126 mg/dL and therefore did not meet the diagnostic criteria. The VA examiner also directed attention to the glucose level of 127 mg/dL in February 2012, but indicated that it was a nonfasting level, and that other glucose levels not identified as fasting or nonfasting during active service were also less than 126 mg/dL. The VA examiner further noted that in-service hemoglobin A1c levels in January 2011 and February 2012 was 5.3 percent and did not meet the diagnostic criteria. The Board notes that in a September 2020 letter, the Veteran’s endocrinologist reiterated his opinion that the onset of the Veteran’s type 2 diabetes mellitus was during active service. The endocrinologist stated that the fasting glucose level of 127 mg/dL in February 2012 would meet the criteria for type 2 diabetes mellitus and that a diagnosis should have been made at the time. The endocrinologist further reported that there is a well-established association between type 2 diabetes mellitus and obstructive sleep apnea. He noted that the two affect each other and are considered equally as dangerous for the long term health and prognosis of the Veteran. Due to the Veteran’s assertion that his diabetes mellitus was caused by prescribed prednisone for his service-connected obstructive sleep apnea with asthma, a VA medical opinion was obtained in April 2020. The VA examiner opined that it is less likely than not that the Veteran’s type 2 diabetes mellitus is secondary to his service-connected obstructive sleep apnea. The VA examiner noted that it is not known whether there is a causal relationship between type 2 diabetes mellitus and obstructive sleep apnea as the association loses statistical significance after adjusting for obesity.” The VA examiner referenced known risk factors for type 2 diabetes mellitus, to include family history, ethnicity, obesity, and lifestyle factors. The VA examiner further opined that it is less likely than not that Veteran’s type 2 diabetes mellitus was caused by his prescribed prednisone use for his lung condition. The VA examiner noted that the Veteran was diagnosed with type 2 diabetes mellitus around 2016, and that although he was treated with inhaled corticosteroids before his diagnosis, he was not treated with oral or systemic corticosteroids. The VA examiner indicated that the effect of inhaled corticosteroids on glucose metabolism appears minimal. The VA examiner also opined that it is less likely than not that the Veteran’s diabetes mellitus was aggravated beyond its natural progression by his service-connected obstructive sleep apnea with asthma. The VA examiner referenced that the Veteran’s diabetes is well controlled as noted by his A1C level and that there was no evidence of diabetic complications. The Board accords greater probative weight to the opinions of the VA examiners of record than the Veteran’s treating endocrinologist. The Board is cognizant that the opinions of the Veteran’s treating endocrinologist and the October 2019 VA examiner were predicated upon whether the February 2012 diagnostic laboratory testing was performed in a fasting or nonfasting manner. Upon review of the test results in question, the Board notes that there is a handwritten indication that the February 2012 results were done while nonfasting. Nevertheless, even if the Veteran is assumed credible and that he fasted on the day of testing, the Veteran did not meet the diagnostic criteria for a diagnosis outlined in his own treating endocrinologist’s July 2018 letter. The Board further notes that the treating endocrinologist’s September 2020 letter contradicted his prior July 2018 letter. The endocrinologist seemingly disregarded the prior diagnostic criteria outlined in the July 2018 letter in favor of a lone glucose level, instead of the two results he initially stated were required. The endocrinologist did not offer any support or rationale as to why the cited American Diabetes Association should be abandoned in the Veteran’s case. Further, May 2013 testing showed that the Veteran’s glucose level of 96 mg/dL was within the normal range, which also undermines the endocrinologist’s opinion of long standing diabetes; the Board notes as well that no support is offered for the assertion of a generally accepted principle. The October 2019 VA examiner similarly cited the criteria for a diagnosis of diabetes mellitus, but was consistent in the determination that the Veteran’s in-service glucose levels did not meet the threshold criteria based upon a review of claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Turning to the Veteran’s contention that service connection for his diabetes mellitus is warranted on a secondary basis, the Board similarly accords greater probative weight to the opinions of the April 2020 VA examiner than the Veteran’s treating endocrinologist. At best, the endocrinologist cites correlation, not causation in his conclusory opinion that “there is a well-established association.” Further, the opinion of the endocrinologist is also future-focused, and framed around the long-term health and prognosis of the Veteran. The April 2020 VA examiner considered and addressed the Veteran’s lay contention, was based on a thorough review of the claims file, and provided sufficient supporting rationales for the opinions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The preponderance of the evidence is against the claim, and service connection for type 2 diabetes mellitus is not warranted. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G.A. Ong, Associate 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.