DIABETES MELLITUS

SHEREEN M. MARCUS · 2025 · Case ID: A25065491

MIXED

Summary

The veteran, who served in the U.S. Army from November 1963 to November 1965, appeals the denial of service connection for diabetes mellitus type II (DM) and related peripheral vascular disease. The veteran also claims exposure to asbestos and other chemicals during service at Fort Richardson, Alaska, and generally asserts his DM is related to service and toxic exposure risk activities (TERA). The Board reviewed the evidence, including service treatment records (STRs), post-service VA treatment records, and a December 2023 VA examination with a nexus opinion. The STRs were silent regarding DM or related complaints during service. Post-service records showed DM beginning in 2010. The VA examiner diagnosed DM and bilateral lower extremity peripheral vascular disease, opining that the DM was less likely than not caused by service or TERA, citing risk factors like family history and lack of direct link between solvent exposure and DM. The Board found the evidence persuasively weighed against service connection for DM, noting the lack of in-service complaints or diagnoses and the decades-long gap until the first post-service diagnosis. The Board also found the VA opinion adequate and probative, despite the examiner noting asbestos exposure, as the examiner concluded no such exposure was relevant to DM development. The peripheral vascular disease claims, secondary to DM, were denied as DM itself was not service-connected. The Board remanded the claim for a right elbow disability, finding the evidence insufficient and a VA examination with a nexus opinion should have been obtained, as the veteran's description of an in-service fall and subsequent pain, swelling, and weakness constituted a potential disability even without a formal diagnosis.

Rationale

No in-service complaints, treatment, or diagnosis of DM.; First documented DM diagnosis decades after service.; VA examiner opined DM was less likely than not caused by service/TERA.; No continuity of symptomatology established.

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

240619-450778

Full Decision Text

Citation Nr: A25065491
Decision Date: 08/01/25 Archive Date: 08/01/25

DOCKET NO. 240619-450778
DATE: August 1, 2025

ORDER

Entitlement to service connection for diabetes mellitus type II (DM) is denied.

Entitlement to service connection for left lower extremity peripheral vascular disease as secondary to DM, is denied.

Entitlement to service connection for right lower extremity peripheral vascular disease as secondary to DM, is denied.

REMANDED

Entitlement to service connection for a right elbow disability is remanded.

FINDING OF FACT

1. The evidence of record persuasively weighs against finding that the Veteran's DM was first incurred in service, within a year of service, or is otherwise etiologically related to service to include toxic risk exposure activities (TERA).

2. The persuasive weight of the evidence is against a finding that the Veteran's bilateral lower extremity peripheral vascular disease was incurred in service, within a year of service, or is attributable to service or a service-connected disability.

CONCLUSION OF LAW

The criteria for entitlement to service connection for diabetes have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

The criteria for entitlement to service connection for a left lower extremity peripheral vascular disease as secondary to DM, have not been met. 38 U.S.C. § §§ 1110, 1117, 1131, 1154(a), 1168, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310.

The criteria for entitlement to service connection for a right lower extremity peripheral vascular disease as secondary to DM, have not been met. 38 U.S.C. § §§ 1110, 1117, 1131, 1154(a), 1168, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty in the United States Army from November 1963 to November 1965.

These matters come to the Board of Veterans' Appeals (Board) on appeal from a February 2024 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO), which was later reviewed and continued in a June 2024 Higher-Level-Review (HLR) decision.

The Veteran appealed the decision in a June 2024, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), electing the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the February 2024 AOJ decision subject to HLR. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the right elbow claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

However, because the Board is remanding the claim of entitlement to service connection for a right elbow disability, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008).

Service Connection

Generally, 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:
fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008).

Service Connection

Generally, 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).

Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013).

Even if a disability cannot be presumptively linked to service, however, due consideration is given whether the condition can nonetheless be attributed to service directly or by any other reasonably raised theory. See Combee v. Brown, 34 F.3d 1039 (1994).

In that regard, under the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act), Section 303, implemented in 38 U.S.C. § 1168, requires a disability examination and medical opinion for certain non-presumptive conditions involving TERA (toxic exposure risk activity). For such claims, VA is required to provide a disability examination and medical opinion when the Veteran submits a claim for compensation, has evidence of a disability, has evidence of participation in a TERA and such evidence is not sufficient to establish service connection for the disability.

In rendering this decision, the Board has reviewed all evidence of record whether discussed in detail. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007) (holding the Board must only discuss the evidence which is relevant to the issues on appeal). To the extent the evidence is found in "approximate balance," the Board will afford the benefit of the doubt in favor of the Veteran. Lynch v. McDonough, 21 F. 4th 776 (Fed, Cir. 2021) (holding that exact equipoise is not required for the benefit of the doubt to be applied, but rather the Veteran is entitled to the benefit of the doubt when the evidence is in approximate balance or "nearly equal").

1. Entitlement to service connection for diabetes mellitus type II (DM) is denied.

The Veteran generally asserts that his currently diagnosed DM is related to service. See September 2023 and January 2024 Claims. He also claims to have been exposed to asbestos while serving at Fort Richardson, Alaska. See September 2022 Supporting Statement.

Here, the AOJ favorably concluded the Veteran was exposed to various cleaning solvents as part of his military duties which included caring for and cleaning various types of weapons. See November 2023 VA Memorandum. The AOJ also concluded he was exposed to various other "Garrision" type exposures, to include asbestos, fuel products, and other chemicals as a result of having been stationed at Fort Richardson, Alaska and as a result of his military occupational specialty (MOS) as a fire crewman, heavy weapons infantryman, and mortar carrier driver. See January 2025 VA Memorandum.

The Veteran's service treatment records (STRs) are silent for any complaints, treatment, or diagnosis related to DM. In fact, during his October 1965 separation examination, neither the Veteran nor the examiner indicated any concerning issues reasonably related to diabetes.

Post service VA treatment records document a history of DM beginning in 2010. See February 2023 VA Treatment Record. Otherwise, the available evidence of record is scarce regarding
exposures, to include asbestos, fuel products, and other chemicals as a result of having been stationed at Fort Richardson, Alaska and as a result of his military occupational specialty (MOS) as a fire crewman, heavy weapons infantryman, and mortar carrier driver. See January 2025 VA Memorandum.

Upon filing his claim seeking entitlement to service connection for diabetes, the Veteran was afforded a VA diabetes examination with medical nexus opinion in December 2023. At which time, the examiner diagnosed the Veteran with diabetes mellitus type II (DM) and bilateral lower extremity peripheral vascular disease. Ultimately, the examiner opined that the Veteran's diabetes was less likely than not "caused by the indicated toxic exposure risk activities after considering the total protentional exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran". The VA examiner specifically noted the Veteran's exposure to solvents as well as his exposure to asbestos within the examination reported. He then opined that the Veteran's DM was less likely than not caused by his exposure to various cleaning solvents as part of his MOS of infantry indirect fire crewman. In support thereof, the examiner stated, "there is no direct link between solvent exposures and development of Diabetes II" and explained the various causes of diabetes and listed the various risk factors normally associated with the development thereof.

Analysis

There is no dispute the Veteran is diagnosed with DM, a history of which is further documented in VA treatment records as early as 2010 and his diagnosis was confirmed upon VA examination in December 2023. However, the Board finds the evidence persuasively weighs against finding the Veteran's DM is related to service, to include presumed exposure to TERAs.

Notably, the Veteran's STRs are silent for complaints, treatment, or symptoms of DM and as indicated above, the first documented report of DM occurred sometime in 2010, decades after service. Importantly, the Veteran has never asserted that he has suffered from DM or symptoms reasonably attributable thereto during or since service, and otherwise the evidence of record does not support such a finding based on the above. Therefore, continuity of symptomatology has not been established.

Moreover, the December 2023 VA medical opinion does not support the Veteran's general assertion that his DM is otherwise related to service, to include exposure to TERAs. The Board acknowledges the examiner's opinion was issued prior to VA's January 2025 memorandum in which exposure to asbestos was specifically indicated as an AOJ favorable finding. Nonetheless, it is noteworthy that the examination report did note asbestos as one of the Veteran's in-service toxic exposures. The issue did not seem to be outcome determinative of the examiner's opinion as the examiner listed various other risk factors and made a point of highlighting the fact that no such toxic exposure would be relevant to the development of the Veteran's disability.

A VA opinion is adequate if it "sufficiently inform[s] the Board of the medical expert's judgment on a medical question and the essential rationale for that opinion." The VA opinion need not discuss each piece of favorable evidence in the record. Likewise, a VA opinion is not nonprobative simply because it does not "explicitly lay out the examiner's journey from the facts to a conclusion." Rather, the VA medical report "must be read as a whole" to determine the examiner's rationale. See Monzingo v. Shinseki, 26 Vet. App. 97, 105-06 (2012).

Here it is clear the VA examiner not only considered the Veteran's presumed TERAs of solvents and other chemicals, but also asbestos. In fact, within the examination report itself, the examiner noted the Veteran's exposure to asbestos. Specifically, the examiner made note of a history of exposure to asbestos with a February 2023 chest x-ray in which "no acute cardiopulmonary processes" were indicated. Therefore, in providing his negative nexus opinion, the Board finds the Veteran's presumed TERA exposures were considered by the December 2023 VA examiner thus, no remand is required to further address the same. 38 U.S.C. § 1168.

Furthermore, the December 2023 examiner supported his opinion by discussing the relevant risk factors for development of DM as well as specifically identifying those that the Veteran possessed, to include a significant family
, but also asbestos. In fact, within the examination report itself, the examiner noted the Veteran's exposure to asbestos. Specifically, the examiner made note of a history of exposure to asbestos with a February 2023 chest x-ray in which "no acute cardiopulmonary processes" were indicated. Therefore, in providing his negative nexus opinion, the Board finds the Veteran's presumed TERA exposures were considered by the December 2023 VA examiner thus, no remand is required to further address the same. 38 U.S.C. § 1168.

Furthermore, the December 2023 examiner supported his opinion by discussing the relevant risk factors for development of DM as well as specifically identifying those that the Veteran possessed, to include a significant family history of DM. See Polovick v. Shineski, 23 Vet. App. 48, 52-53 (2009). The VA medical opinion also expressly considered the Veteran's lay statements and contentions yet found the medical evidence did not support the Veteran's DM was related to in-service TERAs. Accordingly, the Board finds the opinion competent, credible, and probative. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning).

Again, there is no medical opinion or evidence of record which supports the Veteran's contentions that his currently diagnosed DM is related to service, to include exposure to TERAs. Importantly, the Veteran has never asserted that his DM began during service nor that he experienced symptoms of DM since service and the evidence of record otherwise does not indicate as such.

Based on the foregoing, the Board finds that the probative evidence of record does not support the Veteran's contention that his DM is related to service. The Board also finds the evidence persuasively weighs against finding the Veteran's DM is attributable to his presumed TERA exposures.

Accordingly, the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection for DM is not warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102.

2. Entitlement to service connection for left lower extremity peripheral vascular disease as secondary to DM, is denied.

3. Entitlement to service connection for right lower extremity peripheral vascular disease as secondary to DM is denied.

The Veteran initially filed a claim generally seeking entitlement to bilateral lower extremity peripheral neuropathy. See August 2023 and January 2024 Claims. However, the medical evidence of record does not indicate any such diagnosis. The VA December 2023 diabetes, vein and artery conditions examinations revealed a diagnosis of bilateral lower extremity peripheral vascular disease resulting in diminished peripheral pulses and "decreased activity tolerance". The examiner further indicated that said condition was a direct result of his diabetes mellitus type II. Therefore, the Board finds the scope of the Veteran's bilateral lower extremity disability claim is expanded/corrected to include a claim for bilateral lower extremity peripheral vascular disease as secondary to DM and has been recharacterized as noted above. See Clemons v. Shinseki, 23 Vet. App. 1 (2009).

However, in order to prevail under a theory of secondary service connection, the primary disability must first and foremost be service connected. See Wallin v. West, 11 Vet. App. 509, 512 (1998). In contrast, herein the Board finds that service connection is not warranted for the Veteran's DM, and therefore as a matter of law, the Veteran's claim on a secondary service-connection theory of entitlement must be denied. Id.; see also 38 C.F.R. § 3.310 (b).

While the Veteran has conceded TERAs for which development pertaining to these claims has not been completed, such development is not required here. Indeed, TERA examinations are not required where there is a clear etiology that is not associated with the toxic exposure, as is the case here. That is, the Board finds probative the December 2023 VA examiner's opinion that his bilateral lower extremity peripheral vascular disease is due to his DM. Based on this, the Board finds that no further development of the Veteran's claims for service connection for bilateral lower extremity peripheral vascular disease is required.

The Board has also considered whether any lower extremity nerve condition could be directly attributed to service but finds no such supporting evidence. However, the record lacks any evidence that the Veteran experienced any symptoms of either condition during service or is in any way related to service. Indeed, aside from the lack of in-service treatment, complaints, or diagnoses, the post-service medical evidence indicates no clinical diagnosis of any lower extremity nerve condition until decades after service, with impaired functional ability stemming from his nonservice-connected DM upon diagnosis of bilateral lower extremity peripheral vascular disease. See December 2023 VA Examination. Moreover, the Veteran himself has not contended, nor does the record reflect, that his bilateral lower extremity peripheral vascular disease is related to service. Rather, the Veteran has only contended that his claimed conditions are secondary to DM. The Veteran, however, has not been granted service connection for DM from which to seek secondary service connection as the claim for said benefit has been denied in the decision above. Therefore, secondary service connection for bilateral lower extremity peripheral vascular disease, cannot be granted. See generally 38 C.F.R. § 3.310.

Accordingly, the evidence is persuasively against the claims. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection for bilateral lower extremity peripheral vascular disease is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

REASONS FOR REMAND

1. Entitlement to service connection for a right elbow disability, is remanded.

The Board finds the medical evidence is insufficient to decide the issues on appeal and an examination with medical nexus opinion should have been obtained - a pre-decisional duty to assist error. Remand is, therefore, appropriate.

The Veteran generally asserts that he has a current right elbow disability that began during service that has continued ever since. Specifically, he asserts that while stationed at Fort Richardson, Alaska, he slipped and fell on an icy road and sustained an injury to his right elbow that has caused pain, swelling, weakness, and cracking ever since. See January 2024 Supporting Statement.

The Court held in Saunders, that "pain" without a diagnosis can be a disability for VA purposes if it amounts to functional impairment of earning capacity. See Saunders v. Wilkie, 886 F.3d 1356, 1369 (Fed. Cir. 2018).

In this case, the RO never obtained a VA examination with medical nexus opinion on the basis that the Veteran had no current diagnosis. However, per the holding in Saunders, a diagnosis is not required when a claimed disability results in functional impairment. Id. Importantly, the Veteran's service personnel records confirm that he was stationed in Alaska during active-duty service for over a year. Therefore, his contention that he slipped and fell on ice is generally consistent with the circumstances of his service.

Further, the Veteran described not only pain, but functional impairment stemming from his right elbow, to include swelling and weakness. His description at least raises the reasonable possibility of a current disability related to an in-service injury and, therefore, the Board finds it was a pre-decisional duty-to-assist error not to afford him a VA examination. McLendon v. Nicholson, 20 Vet. App. 79 (2006).

While the Board is remanding this matter at this time to obtain a VA examination and medical opinion, the Board is mindful of the holding in Smith v. Wilkie, 32 Vet. App. 332 (2020) and the impact of implicit credibility determinations within remand orders. The Board does not at this time make any determinations regarding the credibility of any evidence currently of record, to include those described in this remand.

The matters are REMANDED for the following action:

1. Schedule the Veteran for a VA examination with an appropriate clinician to determine the nature and etiology of the Veteran's claimed right elbow disability. The claims folder should be made available to and be reviewed by the examiner. All indicated tests and studies should be performed. Following a review of the claims file, the clinician is asked to address the following:

(a.) Identify any and all right elbow disabilities during the pendency of this appeal, even if currently resolved. The examiner is advised that for VA purposes, "pain" resulting in functional impairment of earning capacity is a disability even if not associated with a specific diagnosis.

(b.) For each separate right elbow disability identified, determine whether such disability at least as likely as
DED for the following action:

(b.) For each separate right elbow disability identified, determine whether such disability at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) (i) first incurred in-service, (ii) within a year of service, or (iii) is otherwise etiologically attributable to his active service, to include his described slip and fall accident while stationed at Fort Richardson, Alaska.

In considering any lay statements of record, the clinician should note that the Veteran is competent to attest to matters of which he had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the clinician should provide a fully reasoned explanation.

If medical literature is relied upon, the clinician should identify and specifically cite each reference material used and discuss how it relates to the Veteran's particular medical history. The clinician should specifically discuss any contradictory evidence in the claims file and reconcile that evidence with their findings.

All opinions should be accompanied by supporting rationale explaining how the clinician arrived at the conclusions expressed.

If the clinician determines that s/he cannot provide an opinion without resorting to speculation, s/he should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, s/he should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion.

2. After the above development, and any other indicated development, has been completed, readjudicate the claim.

SHEREEN M. MARCUS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Minnitte, Samuel F.

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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