Citation Nr: 21008355 Decision Date: 02/16/21 Archive Date: 02/16/21 DOCKET NO. 11-12 258 DATE: February 16, 2021 ORDER Service connection for pancreatitis, as secondary to service-connected depressive disorder, is granted. Service connection for diabetes mellitus, type II, as secondary to service-connected pancreatitis, is granted. FINDINGS OF FACT 1. Pancreatitis was caused by the use of alcohol to self-medicate symptoms of the service-connected depressive disorder. 2. Diabetes mellitus, type II, was caused by the now service-connected pancreatitis. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for pancreatitis, as secondary to service connected depressive disorder, have been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310, 3.326. 2. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for diabetes mellitus, type II, as secondary to service connected pancreatitis, have been met. 38 U.S.C. §§ 1101, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310, 3.326. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant, had active service from August 1975 to August 1978. The Veteran also had periods of service with the Army National Guard. This matter came before the Board of Veterans’ Appeals (Board) on appeal from a January 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The instant matter was previously before the Board in January 2017 and October 2020, where the issues on appeal were remanded for additional development. As the instant decision grants service connection for both pancreatitis and diabetes mellitus, type II, which is a complete grant as to the remanding issues on appeal, the Board need not address remand compliance at this time. See Stegall v. West, 11 Vet. App. 268, 271 (1998). As explained in the prior October 2020 Board decision, in an October 2014 statement, the Veteran withdrew a prior Board hearing request. As such, the Board finds there is no hearing request pending at this time as the previous request has been withdrawn. See 38 C.F.R. § 20.704(e). The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). As the instant decision grants service connection for pancreatitis and diabetes mellitus, type II, no further discussion of VA’s duties to notify and assist is necessary. Service Connection Legal Authority Service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Service connection may be granted for disability that is proximately due to or the result of a service-connected disability. An increase in severity of a non service connected disorder that is proximately due to or the result of a service connected disability, and not due to the natural progress of the non service connected condition, will be service connected. Aggravation will be established by determining the baseline level of severity of the non service connected condition and deducting that baseline level, as well as any increase due to the natural progress of the disease, from the current level. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish secondary service connection, there is no temporal requirement inherent in 38 C.F.R. § 3.310(a) that the primary disability be service connected, or even diagnosed, at the time the secondary condition is incurred. Frost v. Shulkin, 29 Vet. App. 131, 134. 1. Service Connection for Pancreatitis The Veteran seeks service connection for pancreatitis on the basis that the pancreatitis was caused by the use of alcohol to self-medicate symptoms of the service-connected depressive disorder. At the outset, the Board notes that the evidence of record supports a finding of current disability of pancreatitis. Such diagnosis can be found within a March 2015 private examination letter and in the report from a February 2019 VA pancreas examination. Next, having reviewed all the evidence of record, lay and medical, the Board finds the evidence at least in equipoise on the question of whether the currently diagnosed pancreatitis was caused by the service-connected depressive disorder. Specifically, the Veteran’s efforts to self-medicate the depressive disorder symptoms with alcohol. Per a March 2015 private opinion letter, a private physician opined that the Veteran’s alcohol use, at least in part, was due to the service-connected depressive disorder. This opinion was based upon the medical literature, an interview with the Veteran, and review of the VA mental health treatment records. In its October 2020 decision, the Board remanded this issue to obtain a secondary service connection opinion, which was received in October 2020; however, review of the October 2020 VA examination report reveals that the opinion is inadequate, as the VA examiner failed to consider whether alcohol use caused by the service connected depressive disorder caused or aggravated the currently diagnosed pancreatitis. Nonetheless, as the evidence of record is sufficient to grant service connection on a secondary causation basis, remand for a new VA medical opinion is unnecessary at this time. Significantly, the VA examiner did state that the medical literature supported that alcohol usage is a risk factor in the development of pancreatitis. Per the above, a private examiner in March 2015 opined that the Veteran’s alcohol use was due, at least in part, to the service-connected depressive disorder symptoms. Per the medical literature, overuse of alcohol can cause pancreatitis. A review of the VA treatment records indicated that the Veteran discussed alcohol consumption history when receiving treatment for the pancreatitis. After reviewing the evidence of record, the private examiner opined that the Veteran’s “pancreatitis is clearly due to his alcohol dependence, which is clearly due to his mental problems.” The Board notes that the VA examiner also appears to render an opinion that the pancreatitis was aggravated by the Veteran’s alcohol usage; however, when reviewing the private opinion letter as a whole, and considering all the other evidence of record, it appears that the private examiner was merely using causation and aggravation interchangeably. Also as discussed above, the Veteran received a VA pancreas examination in February 2019. Per the opinion report, the VA examiner specifically found that the Veteran’s alcohol abuse was the probable cause of the Veteran’s pancreatitis. In sum, a private examiner in March 2015 opined that the Veteran’s alcohol abuse, at least in part, was due to the service-connected depressive disorder. Specifically, the evidence reflects that the Veteran abused alcohol to self medicate the mental health symptoms. Further, both the private examiner in March 2015 and a VA examiner in February 2019 opined the Veteran’s alcohol abuse to be the likely cause of the currently diagnosed pancreatitis. As discussed above, the negative October 2020 VA medical opinion is of no probative value because the VA examiner, while noting that alcohol use is a risk factor in developing pancreatitis, did not consider whether the Veteran’s alcohol abuse was due to the service connected depressive disorder. Absent any other evidence to the contrary, the Board finds that the criteria for service connection for pancreatitis, as secondary to service connected depressive disorder, on a causation basis, have been met. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Service Connection for Diabetes Mellitus, Type II The Veteran seeks service connection for diabetes mellitus, type II, on the basis that the diabetes was caused by the now service-connected pancreatitis. Per the report from a February 2019 VA diabetes mellitus examination, the Veteran has a current diagnosis of diabetes mellitus, type II. Having reviewed all the evidence of record, lay and medical, the Board finds the evidence at least in equipoise on the question of whether the currently diagnosed diabetes mellitus, type II, was caused by the now service-connected pancreatitis. At the conclusion of the February 2019 VA diabetes mellitus examination, the VA examiner opined that it was at least as likely as not that the Veteran’s diabetes mellitus, type II, was due to the now service-connected recurrent pancreatitis. Per the opinion report, while all individuals with chronic pancreatitis are at risk for developing diabetes, this is especially true in cases where, as here, the pancreatitis is longstanding. Further, the VA examiner explained that the recurrent pancreatitis, which was likely due to the Veteran’s history of alcohol abuse, was the more likely cause of the diabetes, rather than other risk factors such as obesity, due to the severity of the diabetes symptoms and complications, to include peripheral neuropathy and erectile dysfunction. The Board notes that in the February 2019 opinion report, the VA examiner used some aggravation language; however, review of the opinion as a whole reflects that the “aggravation” the VA examiner was referencing was the fact that the diabetes residuals are of greater severity due to the Veteran’s pancreatitis than would be expected if the Veteran did not have pancreatitis. The VA examiner is quite clear that the diabetes mellitus, type II, itself was caused by the now service-connected pancreatitis. (Continued on the next page)   The February 2019 VA opinion is supported by a March 2015 private opinion letter. Per the letter, the private examiner cited to a medical journal article that explained that any disease process, such as pancreatitis, that results in diffuse damage to approximately 70 percent of the pancreas may result in diabetes. When considering the evidence found within the Veteran’s claims file, along with the medial literature, the private examiner opined that the Veteran’s diabetes mellitus was more likely than not permanently aggravated by the Veteran’s pancreatitis and alcohol intake. Again, as above, it appears that the private examiner used the term aggravation interchangeably with causation. Even if this were not the case, the findings of the VA examiner in February 2019 support a finding that, pursuant to 38 C.F.R. § 3.310, the Veteran’s diabetes mellitus, type II, was caused, rather than aggravated, by the now service-connected pancreatitis. In sum, a VA examiner in February 2019 specifically opined that the currently diagnosed diabetes mellitus, type II, was caused by the now service-connected pancreatitis. This opinion is supported by the findings of a private examiner in March 2015. Absent any medical opinions to the contrary, and resolving all reasonable doubt in favor of the Veteran, the Board finds that the criteria for service connection for diabetes mellitus, type II, as secondary to now service connected pancreatitis, on a causation basis, have been met. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. J. PARKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Blowers, 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.