Citation Nr: 21055306 Decision Date: 09/07/21 Archive Date: 09/07/21 DOCKET NO. 18-01 356 DATE: September 7, 2021 ORDER Entitlement to service connection for diabetes mellitus II (diabetes) is granted. Entitlement to service connection for hypertension as secondary to diabetes is granted. Entitlement to service connection for gastrointestinal complications, to include bowel obstruction, gastroparesis, gastro-reflux, and malnutrition, secondary to diabetes is granted. Entitlement to service connection for a dental disorder, including loss of teeth, secondary to diabetes is granted. FINDINGS OF FACT 1. The Veteran's diabetes existed prior to his 2010 active duty service and was permanently aggravated beyond its natural progression by his active duty service. 2. The Veteran's hypertension is due to his service-connected diabetes. 3. The Veteran's gastrointestinal complications, to include bowel obstruction, gastroparesis, gastro-reflux, and malnutrition, are due to his service-connected diabetes. 4. The evidence is at least in equipoise that the Veteran's dental disorder, including loss of teeth, is due to his service-connected diabetes and gastrointestinal complications. CONCLUSIONS OF LAW 1. The criteria for service connection for diabetes are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for hypertension as secondary to diabetes are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for service connection for gastrointestinal complications, to include bowel obstruction, gastroparesis, gastro-reflux, and malnutrition, as secondary to diabetes are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for service connection for a dental disorder, including loss of teeth, as secondary to diabetes are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from April 1990 to October 1990 and October 1994 to October 1998, and in the United States Air Force from May 2002 to September 2002, November 2006 to January 2007, March 2009 to May 2009, August 2010 to October 2010, and October 2010 to November 2010, including service in Turkey, Qatar, and Guam. The Board sincerely thanks the Veteran for his service to our country. This matter comes before the Board of Veterans' Appeals (Board) from a March 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In June 2021, the Veteran testified at a virtual Hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the record. Service Connection Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. Service connection may also 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. To substantiate a claim of service connection, there must be evidence of: (1) a current disability; (2) a disease, injury, or event in service; and (3) a nexus or causal relationship between the claimed disability and the disease, injury, or event in service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Chronic diseases identified under 38 C.F.R. § 3.309(a) (including diabetes mellitus II) may be service connected if noted during service and either (1) are shown in service to be chronic, or (2) manifest with continuity of symptomatology. 38 C.F.R. § 3.303 (b). To be shown in service to be chronic, the combination of manifestations must be sufficient to identify the disease entity and there must be sufficient observation to establish chronicity at the time; for example, a manifestation of joint pain is insufficient to permit service connection for arthritis. Id. Alternatively, these chronic diseases are presumptively service connected if they manifest to a degree of at least 10 percent within one year from the date of separation. 38 C.F.R. § 3.307(a)(3). Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc), reconciling, Leopoldo v. Brown, 4 Vet. App. 216 (1993), and Tobin v. Derwinski, 2 Vet. App. 34 (1991). Thus, service connection on a secondary basis may be granted under one of two conditions. The first is when the disorder is proximately due to or the result of a disorder of service origin. In that case, all symptomatology resulting from the secondary disorder will be considered in rating the disability. The second is when a service-connected disability aggravates a nonservice-connected disability. In those cases, VA may only consider the degree of disability over and above the degree of disability prior to the aggravation. VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 CFR part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). A veteran is presumed to be in sound condition, except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service, or where clear and unmistakable evidence establishes that an injury or disease existed prior to service and was not aggravated by service. 38 U.S.C. §§ 1111,1132, 1137. 1. Entitlement to service connection for diabetes mellitus II The Veteran contends either that his diabetes was initially diagnosed within one year of his 2002 deployment to France, or else that it was permanently aggravated beyond its natural progression during his 2010 deployment to Guam. See Hearing Transcript p.10. A December 2001 letter from the Veteran's private treating physician stated that the Veteran had been under the physician's care since November 28, 2001, and that the Veteran was recently diagnosed as diabetic. The physician explained that extensive testing and evaluation had confirmed that the Veteran is a type 2 (non-insulin dependent) diabetic. The physician noted that the Veteran was extremely compliant with all medications and dietary requirements and stated that the Veteran need not restrict activities, work responsibilities, or other issues. Because the evidence of record does not show that the Veteran's diabetes manifest during a period of active duty nor within one year following separation, service connection may not be granted in relation to his active duty from April 1990 to October 1990 or October 1994 to October 1998. The Veteran's diagnosis of diabetes clearly and unmistakably preexisted his periods of active duty in the United States Air Force from May 2002 to September 2002, November 2006 to January 2007, March 2009 to May 2009, August 2010 to October 2010, and October 2010 to November 2010. Thus, the inquiry becomes whether the Veteran's preexisting condition was aggravated by one of these periods of active duty service. The Veteran's service personnel records (SPRs) contains a December 2011 and June 2012 Line of Duty determination that the Veteran's diabetes existed prior to service with service aggravation. The June 2012 line of duty determination states that, while deployed to Guam, the Veteran experienced an event of elevated blood sugar related to his preexisting diabetes, requiring hospitalization. August 2014 and January 2015 Fitness Determinations state that the Veteran had a history of diabetes which was well controlled on oral medication for many years, but became uncontrolled in 2010 with intermittent, persistent nausea and vomiting and he began medication with Lantus insulin and Invokana in 2012. In 2011 he developed gastroparesis that was felt to be a complication of his underlying diabetes. The January 2015 Fitness Determination further states that the Veteran testified that his first episode of gastroparesis occurred while on a 26-day deployment to Guam. Consistent with the January 2015 Fitness Determination, at the June 2021 hearing before the undersigned, the Veteran testified that his diabetes was well-controlled prior to 2010 without hypoglycemic episodes or hospitalizations on oral medication alone. Following his hospitalization in Guam, the Veteran was put on insulin permanently. The March 2017 VA examiner opined that the Veteran's diabetes was not permanently aggravated beyond its natural progression during the period of active duty from October to November 2010. The clinician reasoned that the Veteran suffered a typical complication of poorly controlled diabetes, which is diabetic ketoacidosis. She further reasoned that diabetic ketoacidosis, as a complication of not-well controlled diabetes, can be a normal progression of the disease. The clinician stated that the is evidence of elevated Hgb A1c 8.5 in October 2016, which indicates poor control. The clinician opined that the Veteran's diabetes continued on a normal progression given that is was not well controlled for some years. The Board affords the March 2017 medical opinion minimal probative value as it relates to aggravation of the Veteran's diabetes because the clinician cited to the Veteran's elevated Hgb A1c 8.5 in October 2016, which is significantly later than the deployment during which the Veteran claims his diabetes was aggravated by service. In January 2018, the Veteran submitted private medical opinions from two of his treating physicians. Both physicians stated that the Veteran started to violently vomit after his arrival to Anderson AFB Guam. They reasoned that due to time, climate, food, and lifestyle changes during deployments, the Veteran's type 2 diabetes was prematurely and permanently aggravated, causing him to become type 1 diabetic with gastroparesis, gastral reflux, hypertension, and resulting in extreme weight loss, elevated A1C levels, and uncontrollable bowel movements. They opined that, due to the back-to-back deployments in August to November 2010, the natural progression of the Veteran's type two diabetes was considerably expedited. The physicians further opined that, due to the unnatural rapid progression, the Veteran developed a severe case of gastroparesis and invoking hypertension. Because the Veteran's treating physicians provided a rationale that considers the circumstances of the veteran's service and the progression of his symptoms, the Board affords these opinions high probative value. After careful review, the Board finds that the Veteran is entitled to service connection for diabetes. In making this finding, the Board affords high probative weight to the January 2018 private medical opinions in conjunction with the line of duty and fitness determinations stating that the Veteran's diabetes was well-controlled until his 2010 deployment. The Board finds that a grant of service connection is warranted. See 38 U.S.C. § 5107(b). 2. Entitlement to service connection for hypertension as secondary to diabetes mellitus II The Veteran contends that his hypertension is secondary to his diabetes. See March 2017 Notice of Disagreement. It is not in dispute that the Veteran has a diagnosis of hypertension. Pursuant to this decision, the Veteran has service connection for his diabetes. The remaining question is whether his hypertension is due to or aggravated by his diabetes. The March 2017 VA clinician stated that the Veteran was first diagnosed with hypertension on November 2, 2010. The clinician reasoned that there is evidence in the record that the hypertension was diagnosed and medication treatment (Lisinopril) started on that date. The clinician further reasoned that there were no elevated blood pressure readings in the record prior to 2010, and opined that it is possible that the onset of the Veteran's hypertension was during the active duty period of October to November 2010 and it did not occur prior. Regarding whether the Veteran's hypertension is proximately due to or the result of the Veteran's diabetes the clinician reasoned that its onset was years after the onset of diabetes, which is a typical progression. The clinician opined that the Veteran's hypertension is proximately due to his diabetes. In January 2018, the Veteran submitted private medical opinions from two of his treating physicians. Both physicians opined that, due to the unnatural rapid progression of his diabetes during his 2010 deployment, the Veteran developed a severe case of gastroparesis and invoking hypertension. Finally, the Board notes that an April 2017 Physical Evaluation Board noted that the Veteran's hypertension is associated with his diabetes. The evidence of record demonstrates that the Veteran has a diagnosis of hypertension and is service connected for diabetes. The probative medical evidence of record shows that the Veteran's hypertension is due to his service-connected diabetes. The Board finds that a grant of service connection for hypertension as secondary to diabetes is warranted. 3. Entitlement to service connection for gastrointestinal complications, to include bowel obstruction, gastroparesis, gastro-reflux, and malnutrition, as secondary to diabetes mellitus II The Veteran contends that his gastrointestinal complications are secondary to his diabetes. See March 2017 Notice of Disagreement. It is not in dispute that the Veteran has a diagnosis of gastrointestinal complications, to include bowel obstruction, gastroparesis, gastro-reflux, and malnutrition. See November 2016 VA Examination, January 2018 private medical opinions. Pursuant to this decision, the Veteran has service connection for his diabetes. The remaining question is whether his gastrointestinal complications are due to or aggravated by his diabetes. The March 2017 VA clinician opined that the Veteran's gastrointestinal complications, to include GERD, hiatal hernia, gastroparesis, chronic gastritis and proximal bowel obstruction requiring jejunojejunostomy surgery and multiple feeding tubes placed, are proximately due to or the result of the Veteran's diabetes. Diabetic neuropathy is the broad term and specifically this veteran's enteric neuropathy has resulted in gastroparesis. Nerve cell damage to the intestines and stomach results in gastroparesis. The clinician reasoned that the Veteran's diabetes has not been well controlled, and that he has suffered with two episodes of diabetic ketoacidosis. The clinician further reasoned that the Veteran has undergone more than eight intestinal surgeries as a result and suffered with N/N and malnutrition and poor dentition as a result. Finally, the clinician reasoned that the Veteran has a history of arteriosclerosis (to which diabetes contributes) of the superior mesenteric artery along with chronic stenosis of the left sub-clavian brachiocephalicae and upper extremities veins and noted that poor blood supply to the intestines will also result in gastroparesis. The Veteran has submitted numerous private medical opinions supporting his claim for gastroparesis as secondary to his diabetes. See September, October, and November 2014 medical opinions. The medical opinions state that the Veteran's gastroparesis is a direct result of complications of diabetes and therefore the results are of poor motility of the stomach. The medical opinions note that this leads to chronic nausea and vomiting and can frequently require hospitalization. In January 2018, the Veteran submitted private medical opinions from two of his treating physicians. Both physicians opined that, due to the unnatural rapid progression of the Veteran's diabetes, the Veteran developed a severe case of gastroparesis. The evidence of record demonstrates that the Veteran has a diagnosis of gastrointestinal complications and is service connected for diabetes. The probative medical evidence of record shows that the Veteran's gastrointestinal complications are due to his service-connected diabetes. The Board finds that a grant of service connection for gastrointestinal complications as secondary to diabetes is warranted. 4. Entitlement to service connection for a dental condition as secondary to diabetes mellitus II The Veteran contends that his dental condition is secondary to his diabetes. See March 2017 Notice of Disagreement. It is not in dispute that the Veteran has a diagnosis of complete loss of teeth due to dental caries. See October 2016 VA Examination. Pursuant to this decision, the Veteran has service connection for diabetes, hypertension, and gastrointestinal complications. The remaining question is whether his teeth loss is due to or aggravated by a service-connected disability (to include diabetes and gastrointestinal complications, as discussed above). The Veteran submitted an August 2016 letter from a private Doctor of Dental Medicine which described the Veteran's course of treatment for tooth decay, however the letter did not contain a nexus opinion. The October 2016 VA examiner diagnosed the Veteran with complete loss of teeth due to dental caries, unspecified. The examiner stated that the Veteran's teeth loss is less likely than not due to his repeated, uncontrollable vomiting from 2010 to 2013. The examiner reasoned that impeccable oral hygiene would most likely have prevented any tooth loss or dental decay. The examiner concluded that the Veteran's vomiting "certainly contributed to the teeth loss, but good oral hygiene is always possible and the [V]eteran has not given a suitable reason for being unable to brush and floss his teeth, which would have prevented this problem." While the clinician provided a negative nexus opinion as to causation of teeth loss, the clinician did not provide an opinion as to whether the Veteran's dental condition was aggravated by his diabetes. In contrast to the negative nexus opinion, the clinician stated that the Veteran's vomiting "certainly contributed to the teeth loss". The clinician noted other contributing factors, such as inadequate oral hygiene, but the Board observes that the service-connected disorder need not be the sole contributing factor to the claimed condition. The Board finds the opinion an inadequate basis on which to deny the claim, and notes that the clinician's rationale supports the Veteran's claim. The November 2016 VA examiner, conducting an Intestinal Conditions examination, diagnosed the Veteran with erosion of teeth and partial edentulous secondary to gastroparesis the recurrent multiple vomiting episodes over a recurrent multiple vomiting episodes over a 2 year period and the erosion of the enamel and dentin from teeth from the caustic acidic vomitus material. The examiner noted that the vomiting was significant enough to cause 55lb weight loss and necessitate a feeding tube. As discussed above, the March 2017 VA clinician opined that the Veteran's gastrointestinal complications are proximately due to or the result of the Veteran's diabetes. The clinician stated that the Veteran suffered with poor dentition as a result of the gastrointestinal complications. After careful review, and reading the VA examination reports in the light most favorable to the Veteran, the Board finds that the most probative evidence reaches at least the level of equipoise in the claim of entitlement to service connection for the Veteran's dental condition as secondary to his service-connected disabilities of diabetes and gastrointestinal complications. In making this finding, the Board affords high probative weight to the November 2016 and March 2017 VA examinations which state that the Veteran's gastrointestinal issues resulted in erosion of teeth, partial edentulous, and poor dentition, as well as the rationale of the October 2016 examination which stated that the Veteran's vomiting contributed to his tooth decay. In sum, as the most probative evidence reaches the level of equipoise in the claim at issue, the Board finds that a grant of service connection is warranted. See 38 U.S.C. § 5107(b). M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board O. Halpern 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.