Citation Nr: 21028154 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 17-05 887 DATE: May 10, 2021 ORDER Entitlement to service connection for diabetes mellitus type II is denied. FINDING OF FACT The preponderance of the evidence of record is against finding that the Veteran has had diabetes mellitus type II at any time during or approximate to the pendency of the claim. CONCLUSION OF LAW The criteria for service connection for diabetes mellitus type II is not met. 38 U.S.C. §§ 1110, 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 April 1966 to April 1968, to include service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) from an April 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). This claim was remanded twice by an April 2020 and January 2021 Board decision, for further development. More specifically, the Board directed the RO to provide adequate medical opinions to determine whether the Veteran has a diagnosis of diabetes. Such an opinion was obtained in February 2021. In March 2021, the RO issued a Supplemental Statement of the Case again denying service connection for the Veteran's claimed diabetes mellitus type II. The Board therefore determines that there has been substantial compliance with its previous remand. The matter now returns to the Board. Service Connection Generally, service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The law provides a presumption of service connection for certain diseases that are associated with exposure to herbicide agents and that become manifest within a specified time period in a Veteran who, during active military, naval, or air service, served in the Republic of Vietnam or in or near the Korean Demilitarized Zone (DMZ) during specified periods of time, even if there is no record of evidence of such disease during the period of service. See 38 U.S.C. § 1116; 38 C.F.R. § 3.307(a)(6). Absent affirmative evidence to the contrary, there is a presumption of exposure to herbicides for all Veterans who served in Vietnam during the Vietnam Era. See 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). Here, the Veteran's service personnel records reflect service in the Republic of Vietnam during such era, i.e., April 1966 to April 1968. Therefore, he is presumed to have been exposed to herbicides coincident with such service. If a veteran was exposed to an herbicide agent during active military, naval, or air service, certain diseases shall be service-connected even though there is no record of such disease during service. 38 C.F.R. § § 3.309(e). The diseases listed at 38 C.F.R. § § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the Veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § § 3.307(a)(6)(ii). As relevant to the instant case, diabetes mellitus type II is included in the list of diseases acknowledged to be presumptively related to exposure to herbicide agents. 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; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for diabetes mellitus type II is denied. The Veteran generally contends that his diabetes mellitus type II is due to his service in Vietnam. See September 2013 Statement in Support of Claim. The Veteran's service treatment records are silent to any diabetic symptoms. His post-service treatment records reflect a diagnosis of impaired fasting glucose and diabetes type II in August 2013. See September 2013 Private Treatment Record and February 2014 VA examination. In an August 2013 private examination with Dr. P.Y., the examiner opined that the Veteran has low grade type II diabetes which is more likely than not directly and causally related to his military service as discussed in his initial report, because the Veteran's hemoglobin A1C value was reported by the lab as 5.8 which confirms low grade diabetes. The examiner did not provide the forementioned report. In February 2014, the Veteran was afforded a VA examination where the examiner concluded that the Veteran did not have a diagnosis of diabetes mellitus type I or II but instead found that he had impaired fasting glucose. The examiner explained that the Veteran reported being seen for an elevated glucose but follow up with his personal physician revealed no evidence of elevated glucose. There is no evidence of diabetes mellitus type I or II at this time. In January 2017, the same doctor from the August 2013 examination provided an addendum opinion stating that the lab results he based his initial opinion on was in archives and would forward it when he has access to it. He also stated that he provided the Veteran with another examination, was awaiting the lab results and would provide them when concluded. He further opined that diabetes and impaired fasting glucose are synonymous, thus the Veteran is a low-grade diabetic. The examiner did not provide the forementioned lab results. The April 2020 Board remand found the August 2013, February 2014 and January 2017 opinions to be inadequate for VA purposes and directed the RO to provide new examinations confirming whether the Veteran had diabetes and establishing the difference between diabetes and impaired fasting glucose as a diagnosis. In October 2020, the Veteran was afforded another VA examination. The examiner reported that there was no diagnosis for diabetes mellitus Type I or II. The examiner noted that the Veteran's hemoglobin A1C result was 5.4 and prediabetes ranges from 5.7 to 6.4 and diabetes is over 6.4. The examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. No chronic diagnosis is made for type II diabetes. The Veteran's objective examination was normal, and his symptoms were subjective only; therefore, a nexus has not been established. The January 2021 Board remand found this opinion to be inadequate for VA purposes and directed the RO to provide a new examination complying with the previous remand demand. In March 2021, the Veteran was afforded another VA examination. The examiner reported that there was no diagnosis for diabetes mellitus Type I or II. The examiner noted that while the Veteran had stated that he had a recent physical and at that time, the Veteran was not told to be fasting and had blood work drawn. The Veteran stated that he was told he is borderline and needs to watch what he eats and to exercise. The examiner noted that the Veteran attended repeat labs in February 2021 and that the Veteran does not meet the VA criteria for a diagnosis of diabetes mellitus Type I or II currently. She further explained that if an individual's A1C level is between 5.7 and less than 6.5 percent, their levels will be in the prediabetes range and that if an individual has an A1C level of 6.5 percent or higher, their levels would be in the diabetes range. The examiner noted that for the Veteran, a diagnosis of impaired fasting glucose was given based on hgb A1C of 5.8 in 2013, but impaired glucose tolerance is defined as two-hour glucose levels of 140 to 199 mg per dL (7.8 to 11.0 mmol) on the 75-g oral glucose tolerance test, and impaired fasting glucose is defined as glucose levels of 100 to 125 mg per dL (5.6 to 6.9 mmol per L) in fasting patients. The examiner concluded that in reviewing the Veteran's claims file, there is no record of a glucose tolerance test performed so she is unsure how the Veteran was diagnosed with impaired fasting glucose based on Hgb A1C level only and that the Veteran is pre-diabetic based on the Hgb A1C of 5.8 done in 2013. The examiner noted that there are no other values recorded since then and the most recent fasting glucose done in February 2021 was 87, normal value. Therefore, the examiner determined that the Veteran does not meet VA criteria for a diagnosis of diabetes mellitus, at this time. The examiner considered all evidence of record after thorough review of the claims file, including lay statements properly weighed. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2009); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion...must support its conclusion with an analysis the Board can consider and weight against contrary opinion"). Furthermore, the medical examination report contained clear conclusions with supporting data and a thorough rationale. See Nieves-Rodriguez v. Peake, supra. Thus, this medical opinion is of great probative value. The Board therefore concludes that the Veteran does not have a current diagnosis of diabetes mellitus type II and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). As the record does not reflect a current diagnosis related to diabetes mellitus type II, the cornerstone element of service connection has not been met, and service connection is not warranted. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (stating that service connection presupposes a current diagnosis of the condition claimed, to at least confirm the Veteran has it; without this minimum level of proof, there can be no valid claim). No further discussion of the remaining elements is necessary. The Board acknowledges the Court's holding in Saunders but does not find a basis for determining that there is functional impairment related to a diagnosis of diabetes mellitus type II. See Saunders v. Wilkie, 886 F.3d. 1356 (2018). Moreover, the Veteran has not alleged manifestations of similar severity, frequency and duration as those VA has determined by regulation would cause impaired earning capacity in an average person. Wait v. Wilkie, 33 Vet. App. 8 (2020). While the Veteran may believe his diabetic symptoms had its onset in service or is the result of service, he is not competent to provide a diagnosis or nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of glucose and hemoglobin values. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007); see also Kahana v. Shinseki, 24 Vet. App. 428 (2011). (Continued on the next page) Therefore, the Board concludes that the preponderance of the evidence is against finding that the Veteran meets the criteria for service connection for diabetes mellitus type II. In reaching the conclusion above, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Adeyemi, 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.