Citation Nr: 21009609 Decision Date: 02/23/21 Archive Date: 02/22/21 DOCKET NO. 14-35 291A DATE: February 23, 2021 ORDER Entitlement to service connection for diabetes mellitus, to include as secondary to coronary artery disease and hypertension is denied. FINDING OF FACT The Veteran’s diabetes mellitus is not secondary to service-connected coronary artery disease with hypertension, and is not otherwise related to his active duty service. CONCLUSION OF LAW The criteria for service connection for diabetes mellitus, to include as secondary to coronary artery disease and hypertension have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1971 to August 1991. This case is before the Board of Veterans’ Appeals (Board) on appeal from a May 2010 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In August 2016, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the electronic claims file. In April 2018 and May 2020, the Board remanded the matter for further development. Now the matter is returned to the Board. A veteran is entitled to VA disability compensation if there is disability resulting from personal injury suffered or disease contracted in line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active service. 38 U.S.C. §§ 1110, 1131 (2012). To establish an entitlement to service connection for a disability, a veteran must show: (1) a present disability; (2) an 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, the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for a disability that is proximately due to or the result of an established service-connected disability. 38 C.F.R. § 3.310 (2019). This includes disability made chronically worse by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims stated that “a veteran need only demonstrate that there is an ‘approximate balance of positive and negative evidence’ in order to prevail.” When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b) (2012). For VA to deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App., at 54. The Veteran contends that his diabetes mellitus was caused by exposures to environmental contaminants while working at bases where nuclear weapons and toxic chemicals were stored, immunizations, and vaccinations, and/or it is directly related to his service-connected ischemic heart disease. See August 2009 and February 2011 Statements in Support of Claim. The Veteran submitted a copy of an October 1999 testimony from Dr. J. Barthelow Classen to the Committee on Government Reform of the United States House of Representatives on the increased risk of autoimmunity following immunization in the military and the link between vaccines and diabetes. The Veteran also contends that he had elevated blood sugar levels in service that would now be considered diabetes. See August 2016 Hearing Transcript, at 6. The Board notes the Veteran has not contended direct exposure to Agent Orange or in-county service in the Republic of Vietnam as it relates to his service connection claim for diabetes mellitus. Also, the RO made a formal finding that the Veteran’s herbicide exposure in Thailand cannot be verified after all efforts were deemed exhausted. See October 2020 VA Memorandum. Thus, the Board will focus on the Veteran’s contentions and not examine presumptive service connection for diabetes mellitus type II based on Agent Orange exposure. First, the evidence shows the Veteran’s current diagnosis of diabetes mellitus type II with the date of diagnosis noted as 2010. See e.g., August 2019 Diabetes Mellitus Disability Benefits Questionnaire. Thus, the Board finds that the first Shedden element for service connection is met. The record contains the list of vaccines the Veteran received in service including the vaccines for diphtheria, pertussis, tetanus, polio, typhoid, influenza, tuberculosis, and smallpox. Thus, the Board resolves reasonable doubt in the Veteran’s favor and finds that the second Shedden element for service connection is also met. However, the Board notes that a VA examiner opined in August 2019 that the Veteran’s diabetes mellitus was less likely than not caused by the claimed in-service blood glucose levels, vaccinations, immunizations, and working at bases where nuclear weapons and toxic chemicals were stored during service. The examiner noted that the medical evidence supports the Veteran’s diagnosis of diabetes mellitus type II from 2010, and the Veteran has a family history of diabetes mellitus. The examiner explained that type I diabetes is an autoimmune condition, and it is caused by the body’s attacking its own pancreas with antibodies where the damaged pancreas does not make insulin, but type II diabetes is a different condition where it was used to be called adult-onset diabetes or non-insulin-dependent diabetes. The examiner noted that people who are obese are at particularly high risk of developing type II diabetes due to insulin resistance, and the pancreas have to work overly hard to produce more insulin when one has the type II diabetes condition. The examiner provided that the October 1999 testimony submitted by the Veteran is not relevant in this case, because it was regarding vaccinations and immunizations related to type I diabetes. The examiner also pointed out that the service treatment records are silent for an evaluation, diagnosis or treatment for diabetes mellitus type II condition, and there were no laboratory findings for blood glucose levels in the records to support a diabetes mellitus type II condition during the Veteran’s service. Further, the examiner provided that there is no significant medical literature to support the Veteran’s contention that his diabetes mellitus type II was incurred in or caused by working at bases where nuclear weapons and toxic chemicals were stored. In November 2020, the examiner provided an addendum medical opinion for secondary service connection. The examiner opined that the Veteran’s diabetes mellitus type II is less likely than not proximately due to or the result of any service-connected condition, to include hypertension, coronary artery disease with ventricular arrhythmia, heart block status post myocardial infarction, and implanted cardiac pacemaker. The examiner provided that there is a plethora of causes of diabetes mellitus found in medical literature, but the Veteran’s diagnoses of hypertension, ventricular arrhythmia, heart block status post myocardial infarction, and implanted cardiac pacemaker are separate and distinct from his diabetes mellitus diagnosis. The examiner discussed different studies on insulin resistance in the pathogenesis of type II diabetes where it was found that insulin resistance may be the best predictor of type II diabetes and the vast majority of patients appear to have a genetic risk for type II diabetes. The examiner noted that studies found that insulin resistance becomes more severe with increasing age and weight, thereby unmasking a concurrent defect in insulin secretion in susceptible individuals to cause impaired glucose tolerance and eventually overt hyperglycemia. Further, the examiner opined that the Veteran’s diabetes mellitus is less likely than not aggravated beyond its natural progression by his hypertension, coronary artery disease with ventricular arrhythmia, heart block status post myocardial infarction, and implanted cardiac pacemaker as there is no significant clinical or medical research to support the aggravation. See August 2019 Medical Opinion. Based on above, the Board finds that the Veteran’s diabetes mellitus is not secondary to service-connected coronary artery disease with hypertension, and is not otherwise related to his active duty service. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply here. Consequently, the Board finds that the Veteran’s entitlement to service connection for diabetes mellitus, to include as secondary to coronary artery disease and hypertension is not warranted. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2019). MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. E. Kim, 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.