DIABETES MELLITUS

W. DAKNIS · 2026 · Case ID: A26040129

MIXED

Summary

The veteran, who served in the United States Marine Corps from April 1968 to April 1970, appeals the denial of service connection for hypertension and kidney disease, and the Board reviews the grant of service connection for diabetes mellitus type II (DMII). The veteran claims these conditions are due to conceded exposure to contaminated water at Camp Lejeune. The Board found the initial VA examiner's opinions regarding DMII, hypertension, and kidney disease inadequate due to conclusory rationales and lack of specific explanation linking the conditions to Camp Lejeune exposure. While the Board found the Veteran's DMII claim related to Camp Lejeune exposure, it deemed the private opinion regarding hypertension and kidney disease speculative due to limited data and other more likely etiologies. However, the Board granted service connection for hypertension and kidney disease as secondary to DMII, citing multiple opinions and the January 2026 VA examination report. The claim for obstructive sleep apnea (OSA) was remanded due to an inadequate opinion regarding its connection to service-connected hypothyroidism and other potential causes.

Rationale

AOJ favorably found current diagnosis and Camp Lejeune exposure.; VA examiner's opinion was inadequate due to conclusory rationale and lack of specific explanation.; Board resolved all doubt in Veteran's favor.

Service Branch

MARINE CORPS

Special Benefit

NO SPECIAL BENEFIT

Docket No.

260317-639175

Full Decision Text

Citation Nr: A26040129
Decision Date: 04/29/26 Archive Date: 04/29/26

DOCKET NO. 260317-639175
DATE: April 29, 2026

ORDER

Service connection for diabetes mellitus, type II (DMII), is granted.

Service connection for hypertension is granted.

Service connection for kidney disease is granted.

REMANDED

Entitlement to service connection for obstructive sleep apnea (OSA) is remanded.

FINDINGS OF FACT

1. Resolving all doubt in favor of the Veteran, his DMII is a result of his military service, to include exposure to contaminated water at Camp Lejeune.

2. Resolving all doubt in favor of the Veteran, his hypertension is secondary to his DMII.

3. Resolving all doubt in favor of the Veteran, his chronic kidney disease is secondary to his DMII.

CONCLUSIONS OF LAW

1. The criteria for service connection for DMII have been met. 38 U.S.C. §§ 1101, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309.

2. The criteria for service connection for hypertension have been met. 38 U.S.C. §§ 1110, 1116, 1116A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310.

3. The criteria for service connection for kidney disease have been met. 38 U.S.C. §§ 1110, 1116, 1116A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Marine Corps from April 1968 to April 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a rating decision issued on March 13, 2026, by a Department of Veterans Affairs (VA) Regional Office, hereinafter referred to as the Agency of Original Jurisdiction (AOJ), under the Appeals Modernization Act (AMA).

In March 2026, the Veteran timely appealed the decision by submitting a Decision Review Request: Board Appeal (Notice of Disagreement) (VA Form 10182) and elected the Direct Review docket. Based on the Veteran's election, the Board may only consider the evidence of record at the time of the March 2026 rating decision on appeal. 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.

At the time of the submission of the VA Form 10182, the Veteran waived his right to select a different Board review option. See Williams v. McDonough, 37 Vet. App. 305 (2024). Therefore, the Board may proceed to adjudicate the claim without any prejudice to the Veteran.

Service Connection

1. Entitlement to service connection for DMII.

2. Entitlement to service connection for hypertension.

3. Entitlement to service connection for kidney disease.

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)].

Secondary service connection may be granted for a disability that is due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus
disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)].

Secondary service connection may be granted for a disability that is due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998).

Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, such as cardiovascular diseases, to include hypertension, diabetes mellitus, and organic diseases of the nervous system, to a degree of 10 percent within one year, from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309.

Alternatively, when a disease at 38 C.F.R. § 3.309 (a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303 (b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309 (a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

Additionally, certain diseases have been found to be presumptively related to exposure to contaminants in the water supply at Camp Lejeune. 38 C.F.R. § 3.307 (a)(7). For the purposes of this section, contaminants in the water supply means the volatile organic compounds trichloroethylene (TCE), perchloroethylene (PCE), benzene and vinyl chloride, that were in the on-base water-supply systems located at United States Marine Corps Base Camp Lejeune, during the period beginning on August 1, 1953, and ending on December 31, 1987. A veteran, or former reservist or member of the National Guard, who had no less than 30 days (consecutive or nonconsecutive) of service at Camp Lejeune during the period beginning on August 1, 1953, and ending on December 31, 1987, shall be presumed to have been exposed during such service to the contaminants in the water supply, unless there is affirmative evidence to establish that the individual was not exposed to contaminants in the water supply during that service.

Under 38 C.F.R. § 3.309 (f), if a veteran, or former reservist or member of the National Guard, was exposed to contaminants in the water supply at Camp Lejeune during military service and the exposure meets the requirements of § 3.307(a)(7), the following diseases shall be service-connected even though there is no record of such disease during service, subject to the rebuttable presumption provisions of §3.307(d): (1) Kidney cancer; (2) Liver cancer; (3) Non-Hodgkin's lymphoma; (4) Adult leukemia; (5) Multiple myeloma; (6) Parkinson's disease; (7) Aplastic anemia and other myelodysplastic syndromes; and (8) Bladder cancer.

The Veteran does not have a diagnosis of any of the eight presumed diseases. However, a veteran is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994).

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet.
odysplastic syndromes; and (8) Bladder cancer.

The Veteran contends that his currently diagnosed DMII, kidney disease, and hypertension are caused by his conceded exposure to contaminated water during his service at Camp Lejeune. In this regard, in the March 2026 rating decision, the AOJ favorably found that the Veteran has current diagnoses of such disabilities and that he served at Camp Lejeune during the affected period of water contamination. Under the AMA, the Board is bound by favorable findings. 38 CFR 3.104(c).

Turning to the evidence of record, a March 2026 VA examiner found that the Veteran's DMII was less likely than not related to the indicated toxic exposure risk activities (TERAs), to include the Veteran's exposure to contaminated water at Camp Lejeune. In this regard, the examiner noted the Veteran's risk factors for the development of DMII, which include a history of obesity, advanced age, hypertension, and hyperlipidemia. The examiner also noted additional causes of secondary diabetes, which include diseases of the pancreas, hormonal syndromes that interfere with insulin secretion and that cause peripheral insulin resistance, and drugs (e.g. phenytoin, glucocorticoids, and estrogens).

Here, the Board finds the March 2026 VA examiner's opinion inadequate. Specifically, the examiner provided a conclusory rationale for why the Veteran's DMII is not related to his exposure to contaminated water at Camp Lejeune. Moreover, while the examiner listed multiple risk factors and causes of DMII, an explanation as to how such are related to the Veteran's specific case was not provided. See Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (stating that a medical opinion must support its conclusion with an analysis that the Board can weigh, and a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision).

With respect to the Veteran's hypertension, the March 2026 VA examiner also offered that such is less likely than not caused by the indicated TERA, after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all TERAs, to include water contamination at Camp Lejeune and exposure to PCE, TCE, vinyl chloride, benzene, chemicals and fumes. In support of such opinion, it was noted that for most adults, there is no identifiable cause of high blood pressure. Specifically, primary hypertension tends to develop gradually over many years. In the alternative, secondary hypertension tends to appear suddenly and cause higher blood pressure than primary hypertension and can be caused by various conditions, including OSA, kidney problems, adrenal gland tumors, thyroid problems, and certain birth defects in blood vessels. Additionally, secondary hypertension can be caused by certain medications, to include birth control pills, cold remedies, decongestants, over-the-counter pain relievers, and some prescription drugs such as illegal drugs. The examiner concluded that it is not possible to attribute the Veteran's hypertension to any particular cause or suspected cause.

However, for similar reasons, the March 2026 VA examiner's opinion regarding hypertension is also inadequate. Here, the examiner did not offer an adequate rationale for conclusion that the Veteran's hypertension is not related to his exposure to contaminated water at Camp Lejeune. Furthermore, the examiner did not offer an explanation as to how the risk factors and causes of hypertension are relevant to the Veteran's specific case. See Stefl, supra.

The Board also notes that multiple opinions regarding the Veteran's chronic kidney disease have been obtained throughout the appeal period.

Specifically, a July 2023 VA examiner opined that the Veteran's kidney disease is less likely than not caused by the indicated TERA and provided that there is no evidence of any specific exposures having occurred during deployment which represent an established primary etiology of the condition. However, as the Veteran's TERA is conceded, the opinion is based on an inaccurate factual premise, and therefore, inadequate. Reonal v. Brown, 5 Vet. App. 458, 461 (1993).

Additionally,
how the risk factors and causes of hypertension are relevant to the Veteran's specific case. See Stefl, supra.

The Board also notes that multiple opinions regarding the Veteran's chronic kidney disease have been obtained throughout the appeal period.

Additionally, a VA opinion received in March 2026 notes that there is no objective evidence that would allow for a determination of any connection for Camp Lejeune water contamination, PCE, TCE, vinyl chloride, benzene, chemicals and fumes or other toxic exposure during service. Rather, the examiner listed numerous conditions that cause chronic kidney disease, which include diabetic kidney disease and hypertension.

In this regard, the Board notes that there are multiple opinions which relate the Veteran's chronic kidney disease to his currently diagnosed DMII and hypertension.

Here, in a November 2023 opinion, a VA examiner indicated that the Veteran's kidney disease is more likely secondary to diabetes mellitus, which represents a well-established primary etiology of the condition.

In a June 2024 opinion, a VA examiner noted that the Veteran was diagnosed with DMII, which is poorly controlled, in 2006. Notably, uncontrolled hypertension and diabetes require multiple medications to manage the conditions. Moreover, such are the most common causes of chronic kidney disease and kidney failure. Unmanaged DMII can lead to high blood sugar levels (hyperglycemia), which can damage the kidneys as well as other organs. Therefore, the examiner opined that the Veteran's chronic kidney disease is less likely than not related to TCE, PCE, benzene and/or contaminated water at Camp Lejeune.

In August 2025, a VA examiner also noted that the literature supports that poorly, under controlled hypertension and DMII can cause nephrology consistent with the Veteran's current diagnosis and findings. Additionally, the examiner noted that a history of documented hypertension and DMII predates the diagnosed chronic kidney disease. The examiner further commented that here, the widely accepted medical literature would not support a finding that the Veteran's kidney disease is the result of toxic hazards, when weighed against more likely and exceeding etiologies such as DMII and hypertension. Therefore, the examiner opined that it is less likely than not that the Veteran's kidney disease is due to exposure to contaminated water and other TERAs.

With respect to the Veteran's DMII, a January 2026 VA examination notes that DMII has at least as likely as not permanently aggravated his hypertension and renal disease. In sum, the Veteran's hypertension and renal disease is secondary to his DMII.

Finally, the Board notes that the Veteran submitted an opinion by a private medical practitioner in November 2025. In the opinion, it was noted that while the Veteran was stationed at Camp Lejeune, he underwent vigorous training which likely caused him to consume twice the amount of water as normal. The practitioner noted that significantly, the only water the Veteran would have had access to during this time would have been from the local Camp Lejeune drinking water supply. The medical provider respectfully disagreed with the August 2025 VA examiner's opinion and provided that the Veteran's exposures during his service at Camp Lejeune are well known to cause chronic conditions to include DMII, hypertension, and chronic kidney disease. Additionally, over time, his chronic DMII and hypertension likely further worsened his chronic kidney disease.

In support of his opinion, the medical practitioner cited to multiple publications which noted the presence of TCE and PCE in the drinking water at Camp Lejeune and the correlation of consuming such solvents with the development of insulin resistance, diabetes, and hypertension. However, with respect to hypertension, the examiner noted that there is limited data on the effects of benzene exposure on blood pressure. Nevertheless, the rate of hypertension in those exposed to high levels of benzene was significantly higher than those with less exposure. Moreover, with respect to kidney disease, the medical practitioner indicated that there is no evidence for an increased incidence of chronic kidney disease in those who served at Camp Lejeune during the time of the contaminated drinking water. In humans, exposure to TCE and PCE occurs in complex settings where other etiologies of kidney disease may exist. Nevertheless, he indicated that while kidney disease in those who resided at Camp Lejeune will likely be due to causes other than TCE or PCE exposure, it is not possible to rule out a role for solvent exposure. Therefore
on the effects of benzene exposure on blood pressure. Nevertheless, the rate of hypertension in those exposed to high levels of benzene was significantly higher than those with less exposure. Moreover, with respect to kidney disease, the medical practitioner indicated that there is no evidence for an increased incidence of chronic kidney disease in those who served at Camp Lejeune during the time of the contaminated drinking water. In humans, exposure to TCE and PCE occurs in complex settings where other etiologies of kidney disease may exist. Nevertheless, he indicated that while kidney disease in those who resided at Camp Lejeune will likely be due to causes other than TCE or PCE exposure, it is not possible to rule out a role for solvent exposure. Therefore, relying on the numerous medical publications cited to in the opinion, the medical practitioner opined that it is at least as likely as not that the Veteran's DMII, hypertension, and chronic kidney disease are due to or the result of his exposures at Camp Lejeune. Notably the exposure to high levels of volatile compounds such as TCE, PCE, vinyl chloride, and benzene have been associated with epidemiologic studies with increased risks of metabolic dysfunction, renal impairment, and cardiovascular disease.

First, with respect to the Veteran's currently diagnosed DMII, the Board finds the November 2025 private medical practitioner's opinion. In this regard, the examiner considered all relevant facts and applicable medical principles, and provided a rationale for their conclusions, their opinions are entitled to equal probative weight. Thus, the Board resolves all doubt in favor of the Veteran and finds that his currently diagnosed DMII is related to his acknowledged exposure to contaminated water while stationed at Camp Lejeune.

However, with respect to the Veteran's hypertension and chronic kidney disease, the Board finds the November 2025 medical practitioner's opinion to be somewhat speculative. In this regard, the medical practitioner cited to multiple records which indicate that the studies regarding the relationship between the contaminants and hypertension and kidney disease are limited. Moreover, the articles indicated that there are other more likely causes of hypertension and kidney disease other than solvent exposure. Therefore, the Board finds such opinion to be inadequate with respect to hypertension and kidney disease. See, e.g., Hood v. Shinseki, 23 Vet. App. 295, 298-99 (2005) (medical opinions that are speculative have "little probative value").

Nevertheless, the Board finds the probative evidence of record supports a finding that the Veteran's hypertension and kidney disease are secondary to his DMII. Here, the November 2025 medical practitioner opined that the Veteran's chronic DMII and hypertension likely further worsened his chronic kidney disease. Moreover, the November 2023, June 2024, and August 2025 VA examiners all offered that the Veteran's chronic kidney disease is secondary to his DMII. Notably, a January 2026 VA examination report notes that the Veteran's hypertension and chronic kidney disease are complications of his DMII. Therefore, in light of the award of service connection for DMII, the Board finds that service connection for hypertension and kidney disease, as secondary to DMII, is also warranted.

Therefore, the Veteran's claim for service connection for such disorders is granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

REASONS FOR REMAND

1. Entitlement to service connection for OSA.

The Veteran contends that his currently diagnosed OSA is related to his military service, to include his conceded exposure to contaminated water at Camp Lejeune. In the alternative, he contends that his OSA is caused and/or aggravated by his service-connected conditions, to include tinnitus and hypothyroidism.

With respect to the Veteran's exposure to contaminated water, a November 2023 VA examiner determined that the Veteran's OSA is less likely than not caused by exposure to contaminated water at Camp Lejeune. As rationale, it was provided that there is no evidence of any exposures which represent an established primary etiology of the condition. The examiner opined that the condition is more likely secondary to obesity which represents a well-established primary etiology of the condition.

In June 2024, a VA opinion regarding whether the Veteran's OSA is related to his service-connected tinnitus was requested. At the time, a VA examiner indicated that the Veteran had risk factors of male sex, obesity with a BMI of 29, and large neck documented at size 17. The examiner noted that specifically, tinnitus does not affect OSA. Rather, OSA is caused by the collapse of the upper airway during sleep. Therefore, the examiner concluded that the Veteran's OSA is less likely than not caused and/or aggravated by his service-connected tinnitus.

Here, the Board notes that the June 2024 VA examiner also noted that many
represents a well-established primary etiology of the condition.

Here, the Board notes that the June 2024 VA examiner also noted that many conditions, to include unhealthy lifestyle habits, age, family history, race and ethnicity, and sex, can cause sleep apnea. As relevant, endocrine disorders result in hormone levels that can affect the size and shape of the face, tongue, and airway. People who have low levels of thyroid hormones or high levels of insulin or growth hormone have a higher risk of sleep apnea. Moreover, heart and kidney conditions can cause fluid to build up in the neck, which can block the upper airway.

In February 2025, a different VA examiner provided that the Veteran's OSA is less likely than not due to his service-connected headaches and hypothyroidism conditions as the pathophysiology of both conditions do not have intersection and cannot establish correlation. Here, it was noted that there is no accepted evidence based medical studies that currently link OSA to such conditions. The examiner then reiterated that sleep apnea has a clear etiology due to when throat and tongue muscles are more relaxed causing the airway to become blocked. In adults, the most common cause of sleep apnea is excess weight and obesity, which is associated with soft tissue of the mouth and throat. Factors that increase the risk of this form of sleep apnea include excess weight as fat deposits around your upper airway can obstruct your breathing.

In March 2026, a VA examiner also added that the Veteran's advanced age puts him at increased risk for upper airway obstruction due to age-related loosening and progressive laxity of the pharyngeal walls and the throat muscles causing blockage of air movement as they sleep. Therefore, the examiner concluded that it is much more likely that the Veteran's OSA is due to the small nasopharynx and age-related contraction of the throat causing obstruction. The examiner noted that in this case, the most obvious and likely causes are anatomic. The examiner further noted that there is no evidence of respiratory obstruction or central apnea that could be attributed to any toxic exposures while in service.

Here, the Board finds that the opinion regarding whether the Veteran's OSA is caused or aggravated by his service-connected hypothyroidism is inadequate. Specifically, while the February 2025 VA examiner provided that there is no accepted medical evidence demonstrating a correlation between the diseases, an opinion regarding aggravation was not provided. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013) (stating that a secondary service connection medical opinion was inadequate because it did not discuss aggravation). Moreover, the February 2025 VA examiner did not address the earlier June 2024 VA examiner's opinion which stated that endocrine disorders result in hormone levels that can affect the size and shape of the face, tongue, and airway and that people who have low levels of thyroid hormones or high levels of insulin or growth hormone have a higher risk of sleep apnea.

The AOJ's failure to obtain an adequate opinion regarding all theories of service connection was a pre-decisional duty-to-assist error. Therefore, a remand for an addendum opinion is necessary.

The matter is REMANDED for the following actions:

Forward the record, to include a copy of this Remand, to an appropriate VA examiner in order to obtain an addendum opinion regarding the etiology of the Veteran's OSA.

Following a full review of the record, the examiner should offer an opinion as to whether it is at least as likely as not that the Veteran's OSA is caused and/or aggravated by his service-connected hypothyroidism.

For any aggravation found the examiner should state, to the best of his or her ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology.

In offering an opinion, the examiner should address the June 2024 VA examiner's opinion that endocrine disorders result in hormone levels that can affect the size and shape of the face, tongue, and airway. People who have low levels of thyroid hormones or high levels of insulin or growth hormone have a higher risk of sleep apnea.

A rationale for any opinion offered should be provided
to whether it is at least as likely as not that the Veteran's OSA is caused and/or aggravated by his service-connected hypothyroidism.

A rationale for any opinion offered should be provided.

Wendy Daknis

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Waite, Jennifer

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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