DIABETES MELLITUS

G. WILLIAM RIGGS · 2025 · Case ID: A25017314

DENIED

Summary

The Veteran, an Army Veteran who served from September 1982 to September 1985, appeals the denial of service connection for diabetes mellitus type II, hypertension, bilateral hearing loss, and a heart murmur. The Veteran claimed diabetes secondary to an adjustment disorder and hypertension secondary to tinnitus, while asserting hearing loss was due to acoustic trauma from his MOS as a mortarman. The Board denied all claims, finding the evidence persuasively against service connection for each condition. For diabetes, VA examiners opined it was less likely than not related to service or toxic exposures, citing genetic and environmental factors outside of service as primary causes. For hypertension, examiners similarly found it less likely than not related to service or toxic exposures, attributing it to primary (essential) hypertension with risk factors outside of service, and finding no pathophysiological link to tinnitus. For bilateral hearing loss, the Board found no current right ear hearing loss and that the left ear hearing loss was less likely than not due to noise exposure, citing the low-frequency configuration inconsistent with noise-induced hearing loss and lack of continuity of care or in-service evidence of injury. For the heart murmur, the Board found no current diagnosis of a heart murmur, only a history of congestive heart failure and mitral valve prolapse, and that the murmur, if present, was not linked to service or toxic exposures.

Rationale

Examiner opined diabetes mellitus, type II, is less likely than not proximately due to or the result of adjustment disorder.; Examiner noted diabetes mellitus, type II, is caused by genetic factors, obesity, overeating, lack of exercise, stress, and aging.; Examiner found no medical or scientific evidence linking diabetes mellitus, type II, to the Veteran's exposures.

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

240207-418052

Full Decision Text

Citation Nr: A25017314
Decision Date: 02/26/25 Archive Date: 02/26/25

DOCKET NO. 240207-418052
DATE: February 26, 2025

ORDER

Entitlement to service connection for diabetes mellitus, type II, is denied.

Entitlement to service connection for hypertension is denied.

Entitlement to service connection for bilateral hearing loss is denied.

Entitlement to service connection for a heart murmur is denied.

FINDINGS OF FACT

1. The evidence persuasively shows that the Veteran's diabetes, type II, is not related to his active duty service, to include as a result of toxic exposures.

2. The evidence persuasively shows that the Veteran's hypertension is not related to his active duty service, to include as a result of toxic exposures.

3. The evidence persuasively shows that the Veteran does not have hearing loss in his right ear and that the Veteran's left hearing loss is not related to his active duty service, to include as a result of toxic exposures and in-service noise exposure.

4. The evidence persuasively shows that the Veteran does not have a current heart murmur disability.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for diabetes mellitus, type II, have not been met. 38 U.S.C. §§ 1131, 1168, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C. §§ 1131, 1168, 5107; 38 C.F.R. §§ 3.102, 3.303.

3. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1131, 1168, 5107; 38 C.F.R. §§ 3.102, 3.303.

4. The criteria for entitlement to service connection for a heart murmur have not been met. 38 U.S.C. §§ 1131, 1168, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served honorably in the United States Army from September 1982 to September 1985.

In the February 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket.

In August 2023 and October 2023, the Veteran submitted VA Forms 20-0996, Decision Review Request: Higher-Level Review (HLR), requesting review of August 2023 (diabetes and hypertension) and October 2023 (bilateral hearing loss and heart murmur) decisions, respectively. In December 2023, the agency of original jurisdiction (AOJ) issued the HLR decision on appeal, which considered the evidence of record at the time of the prior August 2023 and October 2023 decisions. Therefore, the Board may only consider the evidence of record at the time of the August 2023 and October 2023 decisions for the respective issues on appeal, which were subsequently subject to higher-level review. If evidence was submitted after the AOJ issued the August 2023 and October 2023 decisions for the respective issues on appeal, the Board did not consider such evidence in its decision. 38 C.F.R. §§ 20.300, 20.301, 20.801.

Service Connection

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 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).

VA's duty to assist includes providing a medical examination when necessary to decide a claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4). Such development is necessary if the evidence of record does not contain sufficient competent medical evidence to decide the claim, but: (a) contains competent evidence of diagnosed disability or symptoms of disability; (b) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period; and (c) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology).

On August 10, 2022, President Biden signed the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act). As part of implementing the PACT Act, VA released subregulatory guidance for claims processors to follow. Subregulatory guidance is a method by which agencies may issue interpretive rules and policy statements, which are not subject to the same rulemaking process as the Code of Federal Regulations (C.F.R.). Much like the M21-1 and other Veterans Benefits Administration-specific (VBA-specific) guidelines, the subregulatory guidance is not binding on the Board. However, the Board is required to discuss any relevant provisions contained in the M21-1 as part of its duty to provide adequate reasons and bases. Overton v. Wilkie, 30 Vet. App. 257 (2018); Nat'l Org. of Veterans' Advocates, Inc. v. Sec'y of Veterans Affairs, 981 F.3d 1360 (Fed. Cir. 2020). As such, if the subregulatory guidance includes a relevant provision, the Board is required to discuss it; if the Board determines that the provision is not for application in a fact-specific situation, then the Board must explain why the provision is not for application in that situation.

Included in the subregulatory guidance are instructions for claims processors to research and complete a TERA Memorandum for any military service that qualifies for a presumption of exposure. See Page 9 of VBA Letter 20-22-10 at 9, Processing Claims Involving the PACT Act, 87 Fed. Reg. 78, 543 (Dec. 22, 2022) (directs that any military service that qualifies for a presumption of exposure must be considered a TERA). A TERA includes any activity that requires an exposure tracking record system for that Veteran, or an activity that the Secretary of VA determines qualifies when considering what is reasonably prudent to protect the health of Veterans. 38 U.S.C. § 1710 (e)(4)(C); see also VBA Letter 20-22-10 at 3. Additionally, under the PACT Act, VA is required to provide a disability examination and medical nexus opinion when a Veteran submits a compensation claim and has evidence of a disability and participation in a TERA, but the evidence is not sufficient to establish service connection for the disability. 38 U.S.C. § 1168 (a) (see PACT Act, Sec. 303). Although VA has an obligation to obtain medical opinions for any service connection claim which cannot be granted where there is evidence of a TERA and of a disability, VA has identified several exceptions to this general obligation where there is no indication of an association between the disability and the TERA. 38 U.S.C. § 1168 (b). Specifically, a TERA opinion is not required for: non-presumptive disabilities based on physical trauma; mental disorders; disabilities determined to have no positive association with herbicide exposure (determined by the Secretary based on cumulative scientific data reported by the National Academies of Science since 1993); and disabilities that manifested during service or with an etiology not associated with toxic exposure. See VBA Letter 20-22-10 at 10-13, Processing Claims Involving the PACT Act, 87 Fed. Reg. 78,543 (Dec. 22, 2022
where there is no indication of an association between the disability and the TERA. 38 U.S.C. § 1168 (b). Specifically, a TERA opinion is not required for: non-presumptive disabilities based on physical trauma; mental disorders; disabilities determined to have no positive association with herbicide exposure (determined by the Secretary based on cumulative scientific data reported by the National Academies of Science since 1993); and disabilities that manifested during service or with an etiology not associated with toxic exposure. See VBA Letter 20-22-10 at 10-13, Processing Claims Involving the PACT Act, 87 Fed. Reg. 78,543 (Dec. 22, 2022).

1. Entitlement to service connection for diabetes mellitus, type II, is denied.

The Veteran contends he developed diabetes mellitus, secondary to an adjustment disorder with mixed anxiety and depressed mood, asserting that a "psychiatric disorder can disrupt sleep and impair a person's metabolism, leading to an increased risk of diabetes." See May 2023 VA Form 21-526EZ, Fully Developed Claim. The Board notes that the Veteran is competent to report symptoms of his disability, but not the etiology. Davdison v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); see also Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (2007).

In connection with his claim, the Veteran was examined in June 2023. The examiner noted the Veteran's diabetes mellitus, type II, diagnosis, made approximately two years ago. He noted the Veteran had become very ill and was admitted to the hospital, where he was diagnosed. The Veteran had high glucose levels, extreme fatigue, blurry vision, increased thirst, and erectile dysfunction. The examiner opined that the Veteran's diabetes mellitus, type II, was less likely than not proximately due to or the result of the Veteran's service-connected condition of adjustment disorder with mixed anxiety and depressed mood, chronic. In support of his rationale, the examiner reasoned that diabetes mellitus, type II, is caused by a combination of genetic factors related to impaired insulin secretion, insulin resistance and environmental factors such as obesity, overeating, lack of exercise and stress, as well as aging. The examiner noted that the main pathophysiological features of diabetes mellitus, type II, are impaired insulin secretion and increased insulin resistance. The impairment of pancreatic ? cell function notably shows progression over time in diabetes mellitus, type II, although aging, obesity, insufficient energy consumption, alcohol drinking, smoking, etc. are independent risk factors for the pathogenesis of diabetes mellitus, type II. The examiner noted that the Veteran's service treatment records and medical records do not sufficiently demonstrate that his diabetes mellitus, type II, is directly caused by an adjustment disorder with mixed anxiety and depressed mood, chronic. The examiner remarked that these are unrelated conditions, and that medical studies/literature and pathophysiological mechanisms are lacking to show that psychiatric disabilities of this kind can directly cause impaired insulin secretion or insulin resistance leading to diabetes mellitus, type II.

The Veteran's records were reviewed in July 2023 for the purposes of a 38 U.S.C. § 1168 toxic exposure risk activity (TERA) opinion. The examiner acknowledged that the records reviewed do not indicate any risk factors outside of military service. The examiner considered the Veteran's claimed exposures to noise, organic pollutants including polyaromatic hydrocarbons (PAH), polychlorinated biphenyls (PCB), as well as hexachlorocyclohexane (HCH), dichlorodiphenyltrichloroethane (DDT), and hexachlorobenzene (HCB). She noted the Veteran's military activity is associated with environmental contamination with chromium, copper, zinc, lead, and cadmium. She acknowledged that personal protective equipment was reportedly not used. The examiner noted the Veteran's use of oral medication (intermittent insulin). Ultimately, she opined that the Veteran's diabetes mellitus, type II is less likely than not caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. In support of her opinion, she reasoned that diabetes mellitus, type II, is characterized by hyperglycemia, insulin resistance, and also relative impairment in insulin secretion; the presence of insulin resistance explains the strong clinical association of diabetes mellitus, type II, with obesity and other insulin-resistant states including genetic susceptibility. The examiner explained that these are the two main risk factors. The examiner explained that the Veteran has risk factors outside of military service that far outweigh the factors identified in the Veteran's
itus, type II is less likely than not caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. In support of her opinion, she reasoned that diabetes mellitus, type II, is characterized by hyperglycemia, insulin resistance, and also relative impairment in insulin secretion; the presence of insulin resistance explains the strong clinical association of diabetes mellitus, type II, with obesity and other insulin-resistant states including genetic susceptibility. The examiner explained that these are the two main risk factors. The examiner explained that the Veteran has risk factors outside of military service that far outweigh the factors identified in the Veteran's TERA assessment. The examiner explained that there is no medical or scientific evidence available that provides any indication of a relationship between the development of the diabetes mellitus, type II, and the Veteran's exposures. The examiner cited to epidemiological and military public health literature in support of her rationale.

The evidence persuasively shows that the Veteran's currently diagnosed diabetes mellitus, type II, is not related to service, to include as a result of his service-connected psychiatric disability and as a result of toxic exposures. The opinions of record are competent, credible, and probative as they collectively are premised upon personal examination of the Veteran, a review of his service treatment records, a review of his VA treatment records, a review of his individual longitudinal exposure record, and a review of the literature. There are no opinions in favor of the claim. As the evidence is persuasively against the claim, the benefit-of-the-doubt rule is inapplicable, and the claims must be denied. Lynch v. McDonough, 21 F4th 776, 781-82 (Fed. Cir. 2021).

2. Entitlement to service connection for hypertension is denied.

The Veteran contends he developed hypertension, secondary to tinnitus, asserting that "[r]esearch published in the NCBI found that 44.4% of people with tinnitus also had hypertension" and that "[t]he connection between the two conditions relates to the delicate network of vessels in your auditory system." See May 2023 VA Form 21-526EZ, Fully Developed Claim. The Board notes that the Veteran is competent to report symptoms of his disability, but not the etiology. Davdison v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); see also Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (2007).

In connection with his claim, the Veteran was examined in June 2023. The examiner opined that it was less likely than not that the Veteran's hypertension was proximately due to or the result of his service-connected tinnitus. The examiner reported that he reviewed the Veteran's records, including his service treatment records. He did not find evidence that the Veteran's tinnitus caused his hypertension, reporting that these are unrelated conditions. He reported that tinnitus, or ringing in the ear, is a symptom of an ear pathology, and that the ears do not affect or cause changes to arterial pressure or blood pressure. He reported that for most adults, there is not an identifiable cause of high blood pressure, and that this type of high blood pressure, called primary (essential) hypertension, tends to develop gradually over many years. He cited a Mayo Clinic article on high blood pressure to support this premise. He reported that medical studies/literature and pathophysiological mechanisms are lacking to show that tinnitus can directly cause an increase in peripheral arterial pressure or hypertension.

The Veteran's records were reviewed in July 2023 for the purposes of a 38 U.S.C. § 1168 TERA opinion. The examiner acknowledged that the records reviewed do not indicate any risk factors outside of military service. The examiner considered the Veteran's claimed exposures to noise, organic pollutants including polyaromatic hydrocarbons (PAH), polychlorinated biphenyls (PCB), as well as hexachlorocyclohexane (HCH), dichlorodiphenyltrichloroethane (DDT), and hexachlorobenzene (HCB). She noted the Veteran's military activity is associated with environmental contamination with chromium, copper, zinc, lead, and cadmium. She acknowledged that personal protective equipment was reportedly not used. The examiner noted the Veteran's use of oral medication. Ultimately, she opined that the Veteran's hypertension is less likely than not caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. In support of her opinion, she reasoned that the Veteran has a
hexane (HCH), dichlorodiphenyltrichloroethane (DDT), and hexachlorobenzene (HCB). She noted the Veteran's military activity is associated with environmental contamination with chromium, copper, zinc, lead, and cadmium. She acknowledged that personal protective equipment was reportedly not used. The examiner noted the Veteran's use of oral medication. Ultimately, she opined that the Veteran's hypertension is less likely than not caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. In support of her opinion, she reasoned that the Veteran has a diagnosis of essential hypertension. She reported that the pathogenesis of primary hypertension (formerly called "essential" hypertension) is most likely the result of numerous genetic and environmental factors that have multiple compounding effects on cardiovascular and renal structure and function. She reported that risk factors include advancing age, family history, race (African American), excessive alcohol consumption, and obesity. She reported that the Veteran has risk factors outside of military service that far outweigh his toxic exposures. She reported that the medical evidence does not include toxic exposure as having a causative relationship to hypertension, citing to Jan Basile and Michael Bloch, OVERVIEW OF HYPERTENSION IN ADULTS (March 2019).

The evidence persuasively shows that the Veteran's currently diagnosed hypertension is not related to service, to include as a result of his service-connected tinnitus and as a result of toxic exposures. The opinions of record are competent, credible, and probative as they collectively are premised upon personal examination of the Veteran, a review of his service treatment records, a review of his VA treatment records, a review of his individual longitudinal exposure record, and a review of the literature. There are no opinions in favor of the claim. As the evidence is persuasively against the claim, the benefit-of-the-doubt rule is inapplicable, and the claims must be denied. Lynch v. McDonough, 21 F4th 776, 781-82 (Fed. Cir. 2021).

3. Entitlement to service connection for bilateral hearing loss is denied.

The Veteran contends that he developed bilateral hearing loss as a result of acoustic trauma experienced in connection with his MOS as a mortarman. See July 2022 VA Form 21-526EZ, Fully Developed Claim. The Board notes that the Veteran is competent to report symptoms of his disability, but not the etiology. Davdison v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); see also Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (2007).

The Veteran sought treatment in May 2022 from VA, for hearing loss. He reported possible hearing loss, worse in the left ear, since the military (1980's). He reported he was in the infantry/mortar division and can remember a specific incident where he "lost his equilibrium/felt dizzy" and heard "buzzing" in his ears, left ear worse. The Veteran felt like his hearing never returned to normal in the left ear following this incident. He also reported bilateral (more so in left ear), constant, mostly non-bothersome tinnitus. He denied other otologic symptoms, at this time. He reported that he had not had his hearing tested in several years and has never worn/tried amplification before.

The Veteran's VA audiology records from July 2022 report that the Veteran was fitted for a left ear hearing aid as treatment for "a known unilateral, asymmetric (worse in left ear), sensorineural hearing loss." During this appointment, the Veteran was "[c]ounseled on [the] difference between ears[,] and how left ear streaming/hearing aid will never be perfect (especially in comparison to his right ear [which has] essentially normal hearing) and he expressed understanding[.]"

In connection with his claim, the Veteran was examined in August 2022. Concerning the Veteran's right ear, the examiner reported: "There are no findings, signs and/or symptoms to support a diagnosis of right ear hearing loss. The claimant has normal hearing (i.e. 25dB HL or less thresholds) from 250-8000Hz Ad [auris dexter, or "right ear"] w/ [with] excellent word recognition, so an etiology for right ear hearing loss is obviously not applicable."

Concerning the Veteran's left ear, the August 2022 examiner indicated that it is less likely than not that the Veteran's left ear hearing loss is a result of military noise exposure. In support of her rationale, the examiner reported that "the low frequency configuration of his left ear unilateral hearing loss [] is not consistent with noise-induced hearing loss." Citing to A Clinician's Guide to Noise-Induced Hearing Loss, the examiner explained: "Noise-induced hearing loss (NIHL) is a hearing loss that typically occurs gradually over time due to prolonged exposure to excessive noise levels greater than 85 decibels (dBA) ... Noise exposure affects both ears and usually causes a hearing loss at 3000, 4000 or 6000 Hz. It does not affect the low frequencies." Citing works from Feldmann (1971) and Penner, et. al. (1981), the examiner explained that "noise-induced sensorineural hearing loss is typically greatest in the highest frequencies and least evident in the lower frequencies, often with a reasonably sharp transitional region between the affected and unaffected frequency regions." The examiner noted that "[a]lthough his MOS was highly probable for hazardous noise exposure, there is no evidence that a hearing loss existed at the time of his separation [in September 19]85 or that a significant decrease in hearing acuity occurred during military service." The examiner acknowledged that "[i]t is recognized that the audiogram is an imperfect measurement; nevertheless, it is accepted as the objective basis for determining noise injuries" adding that "[i]n the absence of objective audiometric evidence of noise injury while in service, an affirmative opinion that the [V]eteran suffered some latent undiagnosed noise injury is utter speculation and directly contradicts the objective evidence of record." While the examiner "concedes noise exposure in service," she posited that "the evidence shows there was no noise injury while in service" and that "[t]his is not at all contradictory." The examiner also cited the Institute of Medicine (IoM) delayed onset noise exposure study for the proposition "that it is difficult, if not impossible, to predict who will be noise exposed and if they are so exposed, who will suffer noise injury," also remarking that "[i]t is important to know that not everyone who is exposed to hazardous noise will suffer noise injury, and that delayed onset hearing loss due to previous noise exposure is unlikely to occur." The examiner also cited Noise and Military Service: Implications for Hearing Loss and Tinnitus (2006), which states: "There is not sufficient evidence from longitudinal studies in laboratory animals or humans to determine whether permanent noise-induced hearing loss can develop much later in one's lifetime, long after the cessation of that noise exposure. Although the definitive studies to address this issue have not been performed, based on the anatomical and physiological data available on the recovery process following noise exposure, it is unlikely that such delayed effects occur." The IoM report further notes: "The committee's understanding of the mechanisms and processes involved in the recovery from noise exposure suggests that a delay of many years in the onset of noise-induced hearing loss following an earlier noise exposure is extremely unlikely." The examiner also noted that "there is no evidence of continuity of care for left ear hearing loss in the 37 years between his separation [in September 19]85 and seeing an audiologist [in May 20]22."

A TERA records review opinion was obtained in May 2023, consistent with 38 U.S.C. § 1168. Concerning the Veteran's left ear, the examiner noted the August 2022 examination's findings of "low frequency hearing loss that is mixed in nature." The examiner noted the Veteran did not participate in combat activity. The examiner remarked that the right hand is used to fire weapons." The examiner noted the Veteran's pre-military noise exposure of power tools and wood working, with hearing protection having been used. The examiner noted the Veteran's MOS as an Indirect Fire Infantryman, which has a high probability for hazardous noise exposure. The examiner noted that the Veteran holds a Marksman Qualification Badge (M16), a Second-Class Qualification Badge (hand grenade) and a Second-Class Qualification Badge (81mm mortar). As a result, the examiner noted that the Veteran was exposed to mortars, M16's, grenades, grenade launchers, tanks, armored personnel carriers (APC's), 9
noted the Veteran did not participate in combat activity. The examiner remarked that the right hand is used to fire weapons." The examiner noted the Veteran's pre-military noise exposure of power tools and wood working, with hearing protection having been used. The examiner noted the Veteran's MOS as an Indirect Fire Infantryman, which has a high probability for hazardous noise exposure. The examiner noted that the Veteran holds a Marksman Qualification Badge (M16), a Second-Class Qualification Badge (hand grenade) and a Second-Class Qualification Badge (81mm mortar). As a result, the examiner noted that the Veteran was exposed to mortars, M16's, grenades, grenade launchers, tanks, armored personnel carriers (APC's), 9mm's and grease guns. The examiner noted that the Veteran "shot with his right hand." The examiner noted the Veteran's post-military noise exposure of firearms, with the use of hearing protection. The examiner noted the Veteran's post-military work in armed security. The examiner noted that she had reviewed the April 2023 TERA Memo. The examiner opined that the Veteran's left ear hearing loss was less likely than not caused by the indicated toxic exposure risk activities, after considering the total potential exposure through all applicable military deployments of the veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. In support of her rationale, the examiner opined that the August 2022 hearing loss exam showed low frequency hearing loss that is mixed in nature. She noted that hearing loss due to noise exposure typically affects hair cells of the cochlea, leading to high pitch hearing loss and/or high frequency threshold shifts. The examiner opined that, given the nature of the Veteran's current hearing loss being mixed as well as low frequency, his current hearing loss is less likely than not due to military noise exposure. The examiner conceded that there are no other indicating factors for cause of this hearing loss, but emphasized that "again, noise would be affecting the high pitch range."

In June 2023, the Veteran again underwent a VA examination to assess the nature and etiology of his hearing loss.

Concerning the Veteran's right ear hearing loss, the June 2023 examiner found that the Veteran's right ear hearing loss was less likely than not caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the veteran and the synergistic, combined effect of all toxic exposure risk activities of the veteran. In support of her rationale, the examiner reported "[t]here is no pathology to warrant a diagnosis or condition that can be related to the claimed toxic exposure." The examiner reported the "Veteran's hearing is within normal limits for the right ear [and t]here is no diagnosis of right hearing loss[; t]herefore, an opinion or etiology cannot be provided for a condition that is not present."

Concerning the Veteran's left ear hearing loss, the June 2023 examiner reported she reviewed the Veteran's exposures of "noise exposure, organic pollutants including polyaromatic hydrocarbons (PAH), polychlorinated biphenyls (PCB), as well as hexachlorocyclohexane (HCH), dichlorodiphenyltrichloroethane (DDT), and hexachlorobenzene (HCB)," and that his "military activity is associated with environmental contamination with chromium, copper, zinc, lead, and cadmium." She noted a review of his records did not indicate any risk factors outside of military service. The examiner noted that the Veteran did not use personal protective equipment (PPE). She opined that the Veteran's left ear hearing loss is less likely than not caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the veteran. She opined that there is no medical or scientific evidence available that provides any indication of a relationship between the development of hearing loss and the TERA. She opined that it is less likely than not that the Veteran's left ear hearing loss is a result of military noise exposure because "[t]he low frequency configuration of his left ear unilateral hearing loss, []is not consistent with noise-induced hearing loss." She also cited to A Clinician's Guide to Noise-Induced Hearing Loss and Feldmann (1971) and Penner, et. al. (1981), who collectively explained that nose-induced hearing loss would impact high frequencies, as opposed to lower frequencies. She also cited to a body of "substantial literature including but not limited to Moore, B. C. J., Lowe, D. A., & Cox, G. (2022)['s] Guidelines for Diagnosing and Quantifying Noise-Induced Hearing Loss, TRENDS IN HEARING
loss is a result of military noise exposure because "[t]he low frequency configuration of his left ear unilateral hearing loss, []is not consistent with noise-induced hearing loss." She also cited to A Clinician's Guide to Noise-Induced Hearing Loss and Feldmann (1971) and Penner, et. al. (1981), who collectively explained that nose-induced hearing loss would impact high frequencies, as opposed to lower frequencies. She also cited to a body of "substantial literature including but not limited to Moore, B. C. J., Lowe, D. A., & Cox, G. (2022)['s] Guidelines for Diagnosing and Quantifying Noise-Induced Hearing Loss, TRENDS IN HEARING, (available at https://doi.org/10.1177/23312165221093156). She reported that while the Veteran's MOS of 11C was highly probable for hazardous noise exposure, there are no records in the Veteran's eFolder to demonstrate that a hearing loss began during service or soon after, adding that the Veteran's current hearing loss in the left ear is not consistent with noise induced hearing loss. She "agreed with the prior examiner that the statement of facts remains the same[ and that t]he [V]eteran's hearing loss in the left ear is not clinically consistent with a noise induced hearing loss."

In consideration of the foregoing, the Board finds that the Veteran (1) does not have a current right ear hearing loss disability and (2) his left ear hearing loss disability is not related to toxic exposures or in-service noise exposure. The opinions of record are competent, credible, and probative as they collectively are premised upon personal examination of the Veteran, a review of his service treatment records, a review of his VA treatment records, a review of his individual longitudinal exposure record, and a comprehensive review of the literature. There are no opinions in favor of the claim. Therefore, the body of evidence tilts against the Veteran's hearing loss claims. As the evidence is persuasively against the claims, the benefit-of-the-doubt rule is inapplicable, and the claims must be denied. Lynch v. McDonough, 21 F4th 776, 781-82 (Fed. Cir. 2021).

4. Entitlement to service connection for a heart murmur is denied.

The Veteran contends generally that he has a heart murmur which is related to service. See July 2022 VA Form 21-526EZ, Fully Developed Claim. The Board has considered the Veteran's reports attributing his heart murmur to service, but the evidence of record does not demonstrate that the Veteran has the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Therefore, the Veteran is not competent to provide an opinion on the etiology of his claimed heart murmur. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (2007).

In connection with his claim, the Veteran was examined in September 2022. The examiner noted the Veteran's cardiac diagnoses of atrial flutter and congestive heart failure, along with a history of a mitral valve prolapse. The examiner noted the Veteran's report that he had a routine check-up in 1982 and was told he had a heart murmur, of which he was told it was nothing to worry about, though over the years he states he was also told there was something wrong with a valve in his heart, and he was eventually diagnosed with congestive heart failure. The examiner noted the Veteran's May 1984 in-service complaints of chest pain with a head cold, and July 1983 in-service complaints of recurrent edema. Ultimately, the examiner opined that the Veteran's condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness, acknowledging that the Veteran's edema and chest pain are symptoms of heart failure, and that there is no evidence to suggest these symptoms of chest pain and edema are related to his diagnosis of heart failure today in the year 2022. The examiner reported there is no official diagnosis of heart failure until the year 2022 which represents a 39-year gap from the first sign of edema in 1983 and his 2022 diagnosis of congestive heart failure. The examiner noted that the Veteran's records failed to show chronicity of care, and therefore no nexus is established. Regarding the course since onset, the examiner noted the Veteran recently just had a heart catheter installed in 2022, with no current symptoms at this time, including chest pain or shortness of breath.

The Veteran was examined again in September 2023 and a TERA opinion was obtained. The examiner reported she was unable to confirm the condition of heart murmur, noting that the Veteran has
. The examiner reported there is no official diagnosis of heart failure until the year 2022 which represents a 39-year gap from the first sign of edema in 1983 and his 2022 diagnosis of congestive heart failure. The examiner noted that the Veteran's records failed to show chronicity of care, and therefore no nexus is established. Regarding the course since onset, the examiner noted the Veteran recently just had a heart catheter installed in 2022, with no current symptoms at this time, including chest pain or shortness of breath.

The Veteran was examined again in September 2023 and a TERA opinion was obtained. The examiner reported she was unable to confirm the condition of heart murmur, noting that the Veteran has a history of congestive heart failure. She noted the Veteran's active duty exposures to: organic pollutants including polyaromatic hydrocarbons (PAH), polychlorinated biphenyls (PCB), hexachlorocyclohexane (HCH), dichlorodiphenyltrichloroethane (DDT), hexachlorobenzene (HCB), chromium, copper, zinc, lead, and cadmium. She observed that the condition of a heart murmur is due to turbulent blood usually caused by stenosis, infection or a complication of rheumatic fever. She reported she did not find evidence to suggest a heart murmur or a causal relationship to the above toxins and determined that she was unable to establish a nexus. The examiner cited to the Mayo Clinic's article on heart murmurs, in support of her rationale. See MAYO CLINIC, Heart Murmurs (available at https://www.mayoclinic.org/diseasesconditions/heart-murmurs/symptoms-causes/syc-20373171).

The evidence persuasively shows that the Veteran does not have a current heart murmur disability. The opinions of record are competent, credible, and probative as they collectively are premised upon personal examination of the Veteran, a review of his service treatment records, a review of his VA treatment records, a review of his individual longitudinal exposure record, and a review of the literature. There are no opinions in favor of the claim. Indeed, there is no evidence the Veteran has a current heart murmur disability, aside from the Veteran's report that forty years ago he recalls being told he had a heart murmur during a check-up. As the evidence is persuasively against the claim, the benefit-of-the-doubt rule is inapplicable, and the claims must be denied. Lynch v. McDonough, 21 F4th 776, 781-82 (Fed. Cir. 2021).

G. William Riggs

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board A. Hennessy

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.

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