Citation Nr: 21007346 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 16-55 153 DATE: February 9, 2021 ORDER Entitlement to service connection for a cerebral vascular accident (CVA), also known as a stroke, to include as secondary to diabetes mellitus type II is granted. FINDING OF FACT Resolving reasonable doubt in the Veteran’s favor his stroke was secondary to his service-connected diabetes mellitus type II disability. CONCLUSION OF LAW The criteria for entitlement to service connection for a cerebral vascular accident (CVA), also known as a stroke, to include as secondary to diabetes mellitus type II have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had honorable active service with the United States Air Force from December 1968 to December 1972. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a March 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In January 2019, the Board issued a decision which denied entitlement to service connection for a stroke to include as secondary to diabetes. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). In March 2020 in a memorandum decision the Court vacated the Board’s January 2019 decision. The Court found that the Board did not err in finding that a June 2014 private examiner’s opinion lacked sufficient rationale to support a grant of service connection. However, the Court found that the Board failed in its duty to provide sufficient reasons or bases for its rejection of favorable, material evidence, in the June 2014 private examiner’s letter. Most recently in December 2020, the Board remanded this matter for additional development. The Board finds that the Regional Office (RO) substantially complied with the Board’s remand instructions and an additional remand to comply with the Board’s directives is not required. See Stegall v. West, 11 Vet. App. 268 (1998). Service Connection Service connection may be established for disability due to a disease or injury that was incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In general, in order to prevail on the issue of service connection the evidence must show: (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). Additionally, a disability that is proximately due to, or results from, another disease or injury for which service connection has been granted, will be considered part of the original disorder. 38 C.F.R. § 3.310(a). Moreover, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 38 C.F.R. § 3.310(b). The analysis in this decision focuses on the most relevant evidence and on what the evidence shows or does not show with respect to the issues denied in this decision. The Veteran should not assume that evidence that is not explicitly discussed in the decision has been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). Entitlement to service connection for a cerebral vascular accident (CVA), also known as a stroke, to include as secondary to diabetes mellitus type II The Veteran contends that he had a stroke secondary to his service-connected diabetes. He also contends that he had a stroke due to exposure to herbicide agents, jet fuels, and jet fumes while in Vietnam. The Veteran’s representative contends that “a review of [the Veteran’s] medical records contemporaneous with his CVA show that his hypertension was well controlled and that his glucose levels remained higher during this period.” The representative also contends that the first examination offered an inaccurate diagnosis, the second one corrected the diagnosis but “went to lengths to deflect causality away from DMII and to hypertension without analyzing the contemporaneous blood pressure readings.” See January 2021 third party correspondence. The July 2012 echocardiographic report shows that the Veteran has a current disability of CVA. The discharge summary indicates that the Veteran’s hypertension and diabetes are risk factors for a CVA. In July 2012 the Veteran’s private doctor submitted a letter on his behalf and indicated that the Veteran tried to control his diabetes with diet and exercise, but “unfortunately, from April 2012 to July 2012 his HgbA1C has risen from 6.6 to 7.4.” Due to the Veteran’s inability to control his diabetes with diet and exercise he was placed on medication. The Veteran’s medical records demonstrate that in April 2012, he had a blood pressure of 130/82; in August 2012, 124/76; and in November 2012, 138/86. In November 2013, the Veteran had a VA examination. The VA examiner opined that it is less likely than not that the Veteran’s stroke is proximately due to or the result of his service-connected diabetes. See VA Examination received January 2014. The examiner explained that although diabetes is a risk factor for cerebrovascular atherosclerotic disease, the Veteran had an embolic stroke. The examiner explained that an embolic stroke was less likely than not associated with the Veteran’s diabetes. The examiner also noted that the Veteran’s diabetes was under control until July 2012. Id. The Board affords this medical opinion no probative value because the examiner provided an opinion based on an inaccurate diagnosis. However, the Board does acknowledge that examiner confirmed that diabetes is a risk factor for cerebrovascular atherosclerotic disease. In June 2014, the Veteran’s board-certified private vascular neurologist with over twenty years of experience, and treating physician provided a medical opinion in the form of a letter on behalf of the Veteran. He stated that, [The Veteran’s] stroke syndrome was a small vessel stroke known as a lacunar stroke. More commonly known as “clumsy hand dysarthria syndrome. This is a very common stroke related to diabetes. Therefore, it is within a reasonable degree of medical certainty that this is strongly related to [the Veteran’s] diabetes. The vascular neurologist responded to the Veteran’s inquiry about the relationship between the Veteran’s diabetes and its relationship to dioxin. The vascular neurologist indicated that it was beyond his depth. See Third Party Correspondence received September 2014. The Board affords the private vascular neurologist’s opinion substantial weight because while the neurologist did not provide a lengthy rationale, he is the Veteran’s treating physician, and has a better understanding of the Veteran’s condition. In addition, he was given the opportunity to speculate as to the relationship between dioxin, and diabetes, and he stated it was outside of his depth. In the December 2020 VA addendum opinion, the examiner opined that it is less likely than not (50 percent probability or less probability) that the Veteran’s stroke was caused by or aggravated by the Veteran’s service-connected disability including, specifically diabetes. As to the rationale, the examiner indicated that the Veteran had a BP of 200/100 which was likely the cause of the lacunar stroke. The examiner indicated that high blood pressure can cause the arteries to narrow. The examiner also noted that the Veteran had an increased blood glucose level, but this is expected to increase during time of acute illness since the body produced counter-regulatory hormones, that are released as part of the physiological “stress” response. The Board affords this medical opinion minimal probative weight because the examiner relied upon a single report by the Veteran that his glucose was stable, and there is contradictory evidence in the record, that demonstrates that the Veteran’s glucose was determined by his physician to not be controlled by diet and exercise, and the Veteran was placed on medication. The examiner also relied upon one elevated blood pressure reading, in determining causation. In addition, the December 2020 VA examiner acknowledged that the Veteran’s A1C levels were up despite full recovery from the lacunar stroke. The Board weighed the Veteran and his representative’s lay statements, the June 2014 private opinion, and the November 2013 and December 2020 VA opinions and determined that the June 2014 private opinion is the most probative evidence. The Veteran had a history of being treated by his private vascular neurologist prior to his stroke, which demonstrates that the neurologist has reviewed the Veteran’s medical history thoroughly before offering a medical opinion. The examiner also avoided offering opinions in areas that were outside of his scope of expertise. The medical evidence throughout the Veteran’s record is consistent, in that diabetes is a risk factor for CVA. The Board finds that the private vascular neurologist’s opinion to be more probative because 1.) the evidence supports the fact that diabetes is a risk factor for CVA, and 2.) the neurologist comprehensively reviewed the Veteran’s medical records prior to offering an opinion, and was the Veteran’s treating physician. The Board is not suggesting that the mere fact that the private vascular neurologist is his treating physician affords his medical opinion more weight but does demonstrate that the physician is familiar with the Veteran’s medical history. The Board acknowledges that the December 2020 VA examiner opined that the Veteran’s hypertension was the cause of the CVA, but the rationale was partially based on incomplete or inaccurate information, and none of the examiners stated that diabetes is not a risk factor for a CVA. Thus, the Board concludes that the private opinion is the most probative evidence. Thus, upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current cerebral vascular accident (CVA), also known as a stroke, is related to his service-connected diabetes mellitus type II. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for (CVA), also known as a stroke is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Quist, 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.