DIABETES MELLITUS

Summary

The veteran served on active duty from July 1990 to December 1992. This case involves appeals for service connection for several conditions, including hypercholesterolemia, central pain syndrome, right shoulder disability, left ankle strain, lumbosacral strain, hypertension, ischemic stroke, hemiplegia/hemiparesis, craniectomy with acquired skull defect, deep vein thrombosis, seizure disorder, obstructive sleep apnea, and entitlement to TDIU. The Board denied service connection for hypercholesterolemia, finding it to be a laboratory finding without disability. Service connection for central pain syndrome and right shoulder disability was also denied due to a lack of current disability and insufficient evidence, with lay testimony deemed incompetent. Service connection for left ankle strain was denied due to a lack of continuous symptoms since service and an unfavorable VA medical opinion stating it was less likely than not related to service. The Board remanded claims for lumbosacral strain, hypertension, ischemic stroke, hemiplegia/hemiparesis, craniectomy, deep vein thrombosis, seizure disorder, obstructive sleep apnea, and TDIU due to duty to assist errors. Specifically, the October 2019 VA opinion for lumbosacral strain was inadequate as it failed to consider service treatment records showing back pain. For hypertension, the evidence was insufficient to determine service connection, requiring a new VA opinion. If hypertension is granted, further opinions are needed for the secondary conditions.

Rationale

Hypercholesterolemia is a laboratory finding, not a disability.; No evidence of impairment of earning capacity or other disease/injury.; Lacking a current disability, service connection may not be granted.

Full Decision Text

Citation Nr: A26035957
Decision Date: 04/16/26	Archive Date: 04/16/26

DOCKET NO. 200827-106575
DATE: April 16, 2026

ORDER

Entitlement to service connection for hypercholesterolemia is denied.

Entitlement to service connection for central pain syndrome is denied.

Entitlement to service connection for right shoulder disability is denied.

Entitlement to service connection for left ankle strain is denied.

REMANDED

Entitlement to service connection for lumbosacral strain, claimed as low back condition, is remanded. 

Entitlement to service connection for hypertension is remanded.

Entitlement to service connection for ischemic stroke is remanded.

Entitlement to service connection for hemiplegia, hemiparesis is remanded.

Entitlement to service connection for craniectomy with acquired skull defect and delayed wound healing is remanded.

Entitlement to service connection for deep vein thrombosis is remanded.

Entitlement to service connection for seizure disorder is remanded.

Entitlement to service connection for obstructive sleep apnea is remanded. 

Entitlement to total disability due to individual unemployability (TDIU) is remanded.

FINDINGS OF FACT

1. Hypercholesterolemia is a laboratory finding and not a disability for VA compensation purposes. 

2. The Veteran does not have current disabilities of either central pain syndrome or right shoulder disability. 

3. The Veteran's left ankle strain is not etiologically related to service. 

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for hypercholesterolemia have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304.

2. The criteria for entitlement to service connection for central pain syndrome have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304, 3.310.

3. The criteria for entitlement to service connection for right shoulder disability have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304, 3.310.

4. The criteria for entitlement to service connection for left ankle strain have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from July 1990 to December 1992. 

This matter is before the Board of Veterans' Appeals (Board) on appeal of a November 2019 decision of the Department of Veterans Affairs (VA) agency of original jurisdiction (AOJ).

In the August 2020 Notice of Disagreement, the Veteran elected the Hearing docket. A Board hearing was held in July 2024. Therefore, the Board may only consider the evidence of record at the time of the November 2019 decision on appeal, as well as any evidence submitted by the Veteran or representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 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 claim(s), 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, for the claims that the Board is remanding, any evidence that 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).

Service Connection

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Generally, the evidence must
 issue another decision on the claim(s), 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, for the claims that the Board is remanding, any evidence that 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).

Service Connection

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Generally, the evidence must show the existence of a present disability, an in-service incurrence or aggravation of a disease or injury, and a causal relationship between the present disability and the disease or injury incurred or aggravated during service ("nexus"). Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). A showing of continuity of symptoms from separation to the present is a factor to be considered in assessing service connection claims.

A disability may also be service connected on a secondary basis by demonstrating that the disability is either proximately due to or the result of an already service-connected disease or injury or aggravated by an already service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995).

1. Service connection for hypercholesterolemia

The Veteran seeks service connection for hypercholesterolemia, claimed as high cholesterol and high triglycerides. The Board finds that service connection is not warranted. 

The term "disability," as used for VA purposes, refers to impairment of earning capacity. See Allen v. Brown, 7 Vet. App. 439 (1995). Hypercholesterolemia, also referred to as high cholesterol, is a "general term for elevated concentrations of any or all of the lipids in the plasma, including hypertriglyceridemia, hypercholesterolemia, etc." Dorland's Illustrated Medical Dictionary, 891 (32nd ed. 2012). Elevated cholesterol is a laboratory finding and not a disability in and of itself for which VA compensation benefits are payable. See 61 Fed. Reg. 20,440, 20,445 (May 7, 1996).

In this case, while there is evidence of hypercholesterolemia, there is no evidence of record suggesting that this condition on its own has caused any impairment of earning capacity or other disease or injury for which service connection may be granted. Lacking a current disability, service connection may not be granted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).  Accordingly, service connection for hypercholesterolemia is denied. 

2. Service connection for central pain syndrome and right shoulder disability

The Veteran seeks service connection for central pain syndrome and right shoulder disability. The Board finds that service connection is not warranted. 

The Veteran's service treatment records do not show any complaints, symptoms, treatment, or diagnoses related to his right shoulder or any central pain condition during active service. Post-service private and VA treatment records similarly do not show any central pain or right shoulder diagnosis or treatment. His left shoulder function was impacted by an ischemic stroke in 2017, but there is no clinical evidence of right-sided complaints. 

The Veteran was afforded a November 2019 VA examination to assess his central nervous system. This diagnosed his ischemic stroke, but it did not identify a central pain syndrome, and pain was not noted as a residual symptom of his stroke. 

Considering this evidence, the Board finds that the Veteran does not have a current disability of either a central pain syndrome or a right shoulder disability. In the absence of such disabilities, there is no basis for service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).

In making this finding, the Board has considered the lay evidence, including the July 2024 testimony from the Veteran and his wife. Notably, their testimony regarding central pain syndrome appeared to conflate this condition with his hemiplegia/hemiparesis. Regarding the right shoulder, they initially stated that he had no diagnosis, but he later stated that a chiropractor found he had fractured his collarbone. However, there is no medical support for this in evidence. As laypeople, they lack the medical expertise to diagnose disabilities that do not have a simple identification. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007
 223, 225 (1992).

In making this finding, the Board has considered the lay evidence, including the July 2024 testimony from the Veteran and his wife. Notably, their testimony regarding central pain syndrome appeared to conflate this condition with his hemiplegia/hemiparesis. Regarding the right shoulder, they initially stated that he had no diagnosis, but he later stated that a chiropractor found he had fractured his collarbone. However, there is no medical support for this in evidence. As laypeople, they lack the medical expertise to diagnose disabilities that do not have a simple identification. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, the lay statements of a belief that the Veteran has current central pain syndrome and right shoulder condition lack competency. 

The Board recognizes that service connection is still possible in the absence of a diagnosis when certain factors, such as pain, are shown to limit functional ability. Saunders v. Wilkie, 886 F.3d 1356, 1364 (Fed. Cir. 2018) ("pain alone can serve as a functional impairment and therefore qualify as a disability"). However, the Board does not observe that the Veteran's complaints rise to the level that impact daily functioning enough to qualify as a separate disability. In this regard, the evidence has not provided a specific description of relevant symptoms. 

For these reasons, the Board finds that service connection is not warranted for central pain syndrome or a right shoulder disability. The claims are denied. 

3. Service connection for left ankle strain 

The Veteran seeks service connection for left ankle strain that he attributes to injuries sustained during a landing in jump school.

As an initial matter, the November 2019 AOJ decision on appeal includes a favorable finding that the Veteran has current disability of left ankle strain. The Board adopts this favorable finding. See 38 C.F.R. § 3.104.

Next, the Board considers whether the clinical evidence shows continuous symptoms of either condition since service. In this regard, the Veteran's service treatment records show he received treatment for left ankle pain after stepping on a rock and hearing a popping sound in June 1991. This was diagnosed as a one- or two-degree (mild or moderate) ankle sprain. He was advised to return for treatment as needed, but there was no further treatment despite seeking treatment for other issues. 

Post-service private treatment records show that the Veteran received treatment for polymyalgia including intermittent left foot/heel pain in March 2013. He was noted to have possible tendonitis of the foot or ankle due to weight. There is no further treatment for the left ankle except in relation to the residuals from his stroke in 2017. 

During an October 2019 VA examination, the Veteran reported injuring his left ankle in a parachute jump, saying he was not allowed to seek treatment at that time. Physical examination was limited due to residual left-sided weakness, atrophy, and non-ambulatory status due to his stroke. No imaging studies were performed or available. The examiner diagnosed left ankle strain. 

Considering the above, the clinical evidence does not show that the Veteran has had continuous symptoms since his active service. Although he was treated briefly for left ankle pain, this appears to be an acute event that resolved without chronic symptoms. There was no other clinical documentation of any left ankle issues until March 2013, and his symptoms at that time appear to be distinct in character from his injury during service. 

Service connection can also be established through lay statements of continuity of symptoms. In this case, however, the lay evidence alone is insufficient to establish service connection. Here, the lay evidence has been inconsistent. For example, during the October 2019 VA examination, he reported that he was not allowed to seek treatment at the time of his injury, while the August 2024 testimony was that he was taken to a hospital and given conservative care. Such inconsistencies do not suggest an intentional effort to mislead, particularly in this case where the Veteran has suffered a cerebrovascular accident. They do, however, suggest that greater reliance is warranted on contemporaneous reports and objective evidence. Moreover, the Board cannot ignore the considerable amount of time that has elapsed from the time the Veteran left service and when his current symptoms were first reported. Therefore, continuity of symptoms is not established by lay evidence. 

Next, despite the lack of continuous symptoms, service connection may be warranted if the evidence otherwise indicates a relationship between the Veteran's current disability and active-duty service. However, the competent evidence fails to establish a nexus between active duty and the Veteran's current left ankle strain. 

In this regard, the October 2019 VA examiner concluded that it was less likely than not that the Veteran's current left ankle strain was incurred during service. They noted that the evidence showed only an isolated incident of
 warranted on contemporaneous reports and objective evidence. Moreover, the Board cannot ignore the considerable amount of time that has elapsed from the time the Veteran left service and when his current symptoms were first reported. Therefore, continuity of symptoms is not established by lay evidence. 

Next, despite the lack of continuous symptoms, service connection may be warranted if the evidence otherwise indicates a relationship between the Veteran's current disability and active-duty service. However, the competent evidence fails to establish a nexus between active duty and the Veteran's current left ankle strain. 

In this regard, the October 2019 VA examiner concluded that it was less likely than not that the Veteran's current left ankle strain was incurred during service. They noted that the evidence showed only an isolated incident of left ankle pain during service that appeared to be benign, and the Veteran had no further mention of an ankle condition in the ensuing years. 

The Board finds this opinion is highly probative. It is consistent with the evidence of record, including treatment records which do not show chronic ankle complaints until many years after he separated from service in 1992. This is despite having treatment for other issues. See Kahana v. Shinseki, 24 Vet. App. 428, 439-40 (2014). To the extent that the examiner did not directly address the Veteran's lay statements, this does not render the opinion inadequate as the Board finds the lay evidence was not probative. 

Accordingly, a nexus is not established between the Veteran's left ankle injury during service and his current left ankle strain. Therefore, service connection is not warranted, and the claim is denied.

REASONS FOR REMAND

1. Service connection for lumbosacral strain

The Board finds that the Veteran's claim for service connection of lumbosacral strain must be remanded to correct a duty to assist error. 

When VA provides an examination or medical opinion, it must either provide an adequate one or notify the veteran why one will not be provided. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The VA medical examiner must be fully cognizant of the Veteran's past medical history. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008).

Here, VA obtained an October 2019 VA medical opinion regarding service connection of lumbosacral strain. The examiner stated that it was less likely than not that the Veteran's current lumbar strain was incurred during service, stating that there was no documentation of a low back condition during service. However, review of the service treatment records shows that the Veteran was treated for back pain in August 1990. Therefore, the October 2019 examiner's opinion was inadequate because it was not based on an accurate depiction of the Veteran's past medical history. Remand is warranted to obtain an adequate medical opinion regarding the etiology of the Veteran's back condition. 

2. Service connection for hypertension, ischemic stroke, hemiplegia, hemiparesis, craniectomy, deep vein thrombosis, seizure disorder, obstructive sleep apnea, and TDIU

The Board finds that remand is also necessary to correct duty to assist errors related to the Veteran's claims for service connection of hypertension, ischemic stroke, hemiplegia/hemiparesis, craniectomy, deep vein thrombosis, seizure disorder, and obstructive sleep apnea as well as entitlement to TDIU.

VA is obliged to provide an examination or obtain a medical opinion in a claim for service connection when the record contains competent evidence that the claimant has current disability or persistent or recurrent symptoms of disability, the record indicates that the disability or symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83.

Here, the Veteran's September 2019 initial claim alleged hypertension that arose during service. VA and private treatment records show that he has a current diagnosis of hypertension. Service treatment records do not directly show hypertension, but they include blood pressure readings with diastolic blood pressure of 90 mm or greater in December 1991 and July 1992. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. However, there is not sufficient evidence to determine whether the Veteran's hypertension arose during service, within one year of service, or is otherwise associated with his active service. Therefore, a VA medical opinion
 (2006); McLendon, 20 Vet. App. at 83.

Here, the Veteran's September 2019 initial claim alleged hypertension that arose during service. VA and private treatment records show that he has a current diagnosis of hypertension. Service treatment records do not directly show hypertension, but they include blood pressure readings with diastolic blood pressure of 90 mm or greater in December 1991 and July 1992. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. However, there is not sufficient evidence to determine whether the Veteran's hypertension arose during service, within one year of service, or is otherwise associated with his active service. Therefore, a VA medical opinion was required, and remand is necessary. 

The Veteran's September 2019 initial claim also contends that his ischemic stroke, hemiplegia/hemiparesis, craniectomy, deep vein thrombosis, seizure disorder, and obstructive sleep apnea are each secondary to his hypertension. Medical records confirm the presence of these current disabilities. He further contends that TDIU was due to his stroke residuals. As such, these claims are inextricably intertwined with the Veteran's claim for service connection of hypertension. If service connection is established for hypertension, then additional medical opinions are required. 

The matters are REMANDED for the following action:

1. Obtain an addendum medical opinion from an appropriate clinician(s) regarding the etiology of the Veteran's lumbosacral strain. The opinion should address the evidence that the Veteran had back pain during service in August 1990. 

2. Obtain medical examination and opinion from an appropriate clinician(s) regarding the etiology of the Veteran's hypertension. The entire claims file should be provided to, and reviewed by, the examiner. Complete rationales should be provided for all opinions given, including discussion of the service treatment records showing elevated blood pressure. 

3. After completing the above, if service connection is warranted for hypertension, obtain medical opinions regarding whether the Veteran's ischemic stroke, hemiplegia/hemiparesis, craniectomy, deep vein thrombosis, seizure disorder, or obstructive sleep apnea are either caused or aggravated by his hypertension.  

 

B.T. KNOPE

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	M. Heger