Citation Nr: 21026154 Decision Date: 04/30/21 Archive Date: 04/30/21 DOCKET NO. 18-01 794 DATE: April 30, 2021 ORDER Entitlement to service connection for hypoglycemia, claimed as due to herbicide exposure, is denied. REMANDED Entitlement to service connection for glaucoma, claimed as due to herbicide exposure, is remanded. Entitlement to service connection for chronic obstructive pulmonary disease (COPD), claimed as due to herbicide exposure, is remanded. Entitlement to service connection for Raynaud’s syndrome, claimed as due to herbicide exposure, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDING OF FACT The preponderance of the evidence of record is against finding that the Veteran has had diabetes, a glycemia-related disability, or any other related disability at any time during or approximate to the pendency of the claim. CONCLUSION OF LAW The criteria for service connection for hypoglycemia have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from September 1968 to February 1972. These matters come before the Board of Veterans’ Appeals (Board) on appeal from November 2015 and July 2018 rating decisions issued by Department of Veterans Affairs (VA) Regional Offices (ROs). This matter was previously before the Board in September 2019, in part, and in March 2020, in its entirety. It was remanded for additional development in March 2020. Upon review of the claims file, the Board is satisfied that there was substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Additionally, the Board notes that in October 2020, the Veteran, by and through his attorney, requested a 120-day continuance of his pending appeals before the Board (in other words, a 120-day extension of the time allowed for submission of additional evidence). As 120 days have elapsed from the date of that letter, the Veteran has submitted additional evidence, and neither the Veteran nor his representative have asked for any additional extension, the Board finds that it may proceed with appellate review of this matter. Finally, the Board notes that the Veteran has requested that this case be advanced on the docket due to serious illness. See letter received February 2, 2021. The motion to advance the case on the docket has been granted. Please note that this appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.902(c). 38 U.S.C. § 7107(b). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred or aggravated during active service. 38 U.S.C. § 1110. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship (nexus) between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Without evidence of disease or injury during service, service connection may still be granted if all of the evidence, including that pertinent to service, establishes that the disability was incurred in service. See 38 C.F.R. § 3.303(d). Additionally, a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected (except as provided in § 3.300(c)) and 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. Furthermore, if a veteran was exposed to an herbicide agent during active service, certain diseases, as listed in 38 C.F.R. § 3.309(e), including type 2 diabetes, shall be service connected if manifest to a degree of 10 percent disabling or more at any time after service. 38 C.F.R. § 3.307(a)(6). A Veteran who, during active military, naval, or air service, served between April 1, 1968, and August 31, 1971, in a unit that, as determined by the Department of Defense (DoD), operated in or near the Korean DMZ in an area in which herbicides are known to have been applied during that period, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iv). As discussed in greater detail in the Board’s March 2020 decision and remand, the Board finds that the evidence is in equipoise as to whether the Veteran served along the Demilitarized Zone (DMZ) while he was stationed in Korea, based on his statements, the photographs of record, the statements from the Veteran’s wife, and his unit’s proximity to the DMZ. Accordingly, in this case, the Veteran is presumed to have been exposed to herbicide agents in service. And while hypoglycemia, COPD, and Raynaud’s disease are not delineated in 38 C.F.R. § 3.309(e) as diseases associated with exposure to certain herbicide agents, the Veteran may still establish service connection on a direct basis, to include as due to herbicide agents. See, e.g., Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Entitlement to service connection for hypoglycemia, claimed as due to herbicide exposure. The Veteran claims that he has hypoglycemia as a result of his exposure to herbicide agents in the Korean demilitarized zone (DMZ). For the following reasons, the Board finds that the Veteran is not entitled to service connection for hypoglycemia. The Veteran’s service treatment records (STRs) do not reflect any in-service complaints or diagnosis of hypoglycemia, diabetes, or any other glycemia-related disability. His post-service medical treatment records include a February 2019 private treatment note in which it is stated that the Veteran has a medical/surgical history including diabetes; however, there is no indication of any testing evidencing diabetes, nor is there any indication as to how it was determined that the Veteran had a history of diabetes (for example, there is no indication whether diabetes was included based on the Veteran’s reported history alone, or whether it was included based on the results of some type of testing and/or the findings of physicians or other competent healthcare professionals). The post-service medical treatment records do not otherwise indicate that the Veteran has a diagnosis of diabetes, any functional limitation related to hypoglycemia, or any other glycemia-related disability; in other words, these records do not otherwise indicate that the Veteran has a related disability. After the Board’s March 2020 remand, the Veteran was afforded a VA examination in September 2020. The examiner completed a Diabetes Mellitus Disability Benefits Questionnaire (DBQ) in which the examiner indicated that the Veteran has a diagnosis of hypoglycemia, dated the day of that examination, but not of diabetes mellitus nor any other related conditions/disabilities. The examiner indicated that the results of a urinalysis that was performed in connection with the Veteran’s examination were within normal limits. The examiner also indicated that the Veteran’s condition does not impact his ability to work. Finally, in a separate Medical Opinion DBQ, the examiner stated that the Veteran does not have diabetes mellitus type 2 or any other conditions that may have caused his hypoglycemia and that his hypoglycemia is idiopathic. After review of the claims file, and upon consideration of the foregoing, the Board finds that the weight of the evidence does not establish a current disability manifested by hypoglycemia. Elevated blood sugar levels (hypoglycemia) represent a laboratory finding, and therefore are not considered to be an actual disability in and of itself for which VA compensation benefits are payable. See 61 Fed. Reg. 20,440, 20,445 (May 7, 1996) (Diagnoses of hyperlipidemia, elevated triglycerides, and elevated cholesterol are actually laboratory results and are not, in and of themselves, disabilities. They are, therefore, not appropriate entities for the rating schedule). While the records do demonstrate a laboratory finding of hypoglycemia, there is no evidence of a diagnosis of a disability manifested by hypoglycemia or a description of any resulting functional impairment. The term “disability” in 38 U.S.C. § 1110 refers to the functional impairment of earning capacity, and in the context of a veteran’s disability claim, symptoms such as pain may be considered a disability if they diminish the body’s ability to function, whether they are diagnosed as connected to a current underlying condition or not. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). The first requirement for any service connection claim is evidence of a current disability. The Court has held that Congress specifically limited entitlement to service connected benefits to cases where there is a current disability. “In the absence of proof of a present disability, there can be no valid claim.” Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Without competent evidence of a diagnosed disability, service connection for the disorder cannot be awarded. See Brammer, supra; Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004) (holding that service connection requires a showing of current disability) ; see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (holding that a grant of service connection requires that there be a showing of disability at the time of the claim, as opposed to sometime in the distant past). The Board notes that while the Veteran is competent to report symptoms that he has experienced and observed, he is not competent to opine as to which symptoms are caused by his hypoglycemia. Such an issue is medically complex, as a diagnosis of hypoglycemia and a competent opinion as to a nexus between it and alleged symptoms requires medical training and credentials. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As hypoglycemia represents a laboratory finding, and there is no medical evidence that the Veteran has a current disability manifested by hypoglycemia, the competent evidence does not establish the presence of a current disability. Furthermore, even if the Board were to find that the Veteran does have a hypoglycemia-related disability, hypoglycemia is not a disease listed in 38 C.F.R. § 3.309(e) as a disease associated with exposure to certain herbicide agents, and there is no competent evidence that it was incurred during the Veteran’s active service or as a result of his in-service exposure to herbicide agents in the claims file. The Veteran’s STRs and subsequent medical records evidence no such in-service incurrence, nor does the competent medical evidence of record indicate that it was caused by exposure to herbicide agents. Neither the Veteran nor his representative have offered any medical evidence demonstrating the Veteran’s hypoglycemia is related to herbicide agent exposure. Accordingly, the claim for service connection for hypoglycemia is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the competent, probative evidence is against the claim, there is no reasonable doubt to be resolved, and that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1, Vet. App. 49, 53-56 (1990). REASONS FOR REMAND 1. Entitlement to service connection for glaucoma, claimed as due to herbicide exposure, is remanded. 2. Entitlement to service connection for chronic obstructive pulmonary disease (COPD), claimed as due to herbicide exposure, is remanded. 3. Entitlement to service connection for Raynaud’s syndrome, claimed as due to herbicide exposure, is remanded. The Veteran submitted a January 2021 independent medical evaluation report in support of this claim, and in that report, the authoring physician/evaluator stated that “[g]iven his history of the two diseases and the fact that his hypertension is service-connected, it is at least as likely as not that this gentleman’s hypertension contributed to the development of his glaucoma.” The examiner also opined that “[g]iven that this gentleman has a history positive for hypertension and has subsequently developed Raynaud’s, it is as least as likely as not that this gentleman’s hypertension contributed to the development of his Raynaud’s syndrome.” The Board notes that the examiner indicated that the Veteran’s hypertension at least as likely as not contributed to these conditions, not whether it caused or aggravated those conditions. Furthermore, the physician’s rationale regarding glaucoma cites medical literature finding an association between hypertension and glaucoma, but not necessarily a causal relationship. The Board finds that additional information, in the form of another VA medical opinion, is needed prior to adjudication of this appeal. Specifically, on remand, medical opinions should be obtained on whether the Veteran’s hypertension has caused or aggravated his glaucoma or Raynaud’s syndrome. Furthermore, the Veteran’s VA treatment records contain ophthalmologic consult notes discussing his glaucoma and an optic nerve head NFL hemorrhage which note that the Veteran has Waldenstrom macroglobulinemia, which is a form of non-Hodgkin’s lymphoma, for which the Veteran has been granted service connection. Thus, the Board finds that the question of whether the Veteran has an eye disorder that is caused by his service-connected non-Hodgkin’s lymphoma has been raised. Therefore, on remand, the examiner should also opine whether the Veteran has an eye disability that is caused or aggravated by his service-connected non-Hodgkin’s lymphoma. Additionally, in a September 2020 Respiratory Conditions DBQ, the examiner wrote in the Medical History section that the date of onset of the Veteran’s COPD and/or symptoms was 1971. It is not clear whether that date of onset was based solely on the Veteran’s statements during the examination or reported medical history or some other medical documentation. While the examiner did opine that the Veteran’s COPD was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness, the examiner did not provide an adequate rationale regarding whether it was incurred during service. Considering the indication that the date of onset of COPD was in 1971, the Board finds that another VA medical opinion should be obtained regarding whether the Veteran’s COPD was incurred during his active service. 4. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. The Board finds that the issue of entitlement to TDIU is inextricably intertwined with the Veteran’s claims of entitlement to service connection for glaucoma, COPD, and Raynaud’s syndrome. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim). As such, consideration of entitlement to TDIU must be deferred pending the outcome of the Veteran’s claim of entitlement to service connection for glaucoma and Raynaud’s syndrome. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision on the matter). Additionally, the Veteran’s VA treatment records contain an October 2020 treatment note noting the Veteran’s “waldenstrom’s macroglobulinemia/lymphoplasmacytic lymphoma of unknown significance” and discussing the Veteran’s reports of progressive fatigue, weakness, bone pain, and peripheral neuropathy for several months. The note indicates that the Veteran’s symptoms correspond with a progressive elevation in his serum IgM levels and progressive elevation of serum viscosity. The Board finds that the note may indicate that the Veteran has some disabling symptoms related to his service-connected non-Hodgkin’s lymphoma. Thus, the Board finds that in connection with this claim of entitlement to TDIU, the Veteran should be afforded a VA examination for the purpose of assessing the current severity of his service-connected non-Hodgkin’s lymphoma. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s glaucoma is at least as likely as not: (a.) proximately due to the Veteran’s service-connected hypertension or non-Hodgkin’s lymphoma; or (b.) aggravated beyond its natural progression by the Veteran’s service-connected hypertension or non-Hodgkin’s lymphoma. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s COPD at least as likely as not had onset during his active military service. The examiner must address the September 2020 Respiratory Conditions DBQ which notes the date of onset of the Veteran’s COPD and/or symptoms was 1971. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s Raynaud’s syndrome is at least as likely as not: (a.) proximately due to the Veteran’s service-connected hypertension; or (b.) aggravated beyond its natural progression by the Veteran’s service-connected hypertension. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected non-Hodgkin’s lymphoma. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner is specifically asked to clearly describe the Veteran’s non-Hodgkin’s lymphoma-related functional limitations, and to consider the Veteran’s lay statements and buddy statements when doing so (for example, the January 2021 statement from the Veteran’s wife and the Veteran’s own January 2021 statement). Tiffany Dawson Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Banks, 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.