DIABETES MELLITUS

TIFFANY DAWSON · 2026 · Case ID: A26040570

MIXED

Summary

The veteran served from October 1975 to October 1979. The veteran appeals the denial of service connection for diabetes mellitus and chronic kidney disease, both claimed as secondary to service-connected tinnitus. The Board denied these claims, finding that the medical evidence did not establish a nexus between the tinnitus and either diabetes mellitus or chronic kidney disease. The Board relied on VA medical opinions which concluded that these conditions were less likely than not related to tinnitus, citing a lack of supporting medical literature for a pathophysiological relationship. The Board found these opinions effectively addressed the secondary service connection inquiry and assigned them great probative value, noting the veteran did not contest their adequacy. Consequently, the Board denied service connection for diabetes mellitus and chronic kidney disease. The veteran also appeals the denial of service connection for a lumbosacral strain with degenerative arthritis and obstructive sleep apnea. These claims were remanded for further development. For the lumbosacral strain, the Board found the prior VA opinions inadequate because they did not address the veteran's contention of continuous symptoms since service. A new VA examination is ordered to assess the nexus for this condition and continuous symptomatology. For obstructive sleep apnea, the Board found remand warranted because the prior VA opinions did not address the veteran's submitted articles and generic nexus opinion linking sleep apnea to tinnitus. A new opinion is required to assess the secondary relationship between tinnitus and sleep apnea, as well as potential aggravation. The Board also noted that a GERD-related secondary theory for sleep apnea, raised late in the appeal, should be considered upon remand.

Rationale

No medical nexus established between tinnitus and diabetes mellitus.; VA opinions found conditions to be separate entities.; Medical literature failed to demonstrate a causal relationship.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

260121-626875

Full Decision Text

Citation Nr: A26040570
Decision Date: 04/30/26 Archive Date: 04/30/26

DOCKET NO. 260121-626875
DATE: April 30, 2026

ORDER

Entitlement to service connection for diabetes mellitus is denied.

Entitlement to service for chronic kidney disease is denied.

REMANDED

Entitlement to service connection for a lumbosacral strain with degenerative arthritis is remanded.

Entitlement to service connection for obstructive sleep apnea is remanded.

FINDINGS OF FACT

1. The Veteran's service-connected tinnitus neither caused nor aggravates his diabetes mellitus.

2. The Veteran's service-connected tinnitus neither caused nor aggravates his chronic kidney disease.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for diabetes mellitus under a secondary theory of entitlement have not been met. 38?U.S.C. §§?1110, 1131, 5107; 38?C.F.R. §§?3.102, 3.310.

2. The criteria for entitlement to service connection for chronic kidney disease under a secondary theory of entitlement have not been met. 38?U.S.C. §§?1110, 1131, 5107; 38?C.F.R. §§?3.102, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service from October 1975 to October 1979.

Procedural History

In the January 2026 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. In it, the Veteran requested the Board review decisions with dates of November 30, 2017 and February 24, 2022. Those decisions, per the Veteran, concerned "back pain," "knee pain," "sleep apnea," "chronic kidney disease," and "diabetes mellitus." The Board has not identified any rating decision or notification of a rating decision with those dates. Even if it had, the VA Form 10182 would have been untimely vis-à-vis those decisions. Therefore, the Board considered whether the VA Form 10182 could apply to the two rating decisions for which it was timely: March 2025 and April 2025. Having done so, the Board finds the VA Form 10182 applies to the four issues identified on the title page the Agency of Original Jurisdiction (AOJ) adjudicated in the March 2025 rating decision. Because the AOJ did not adjudicate entitlement to any benefits concerning the Veteran's knees in either the March 2025 or April 2025 rating decision, the Board finds that issue is not on appeal.

The March 2025 rating decision on appeal constitutes an initial decision; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies.

Because the Veteran elected the Direct Review docket, the Board may only consider the evidence of record at the time of the March 2025 AOJ 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.

For the diabetes mellitus and chronic kidney disease claims, 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 claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

For the lumbosacral strain with degenerative arthritis and obstructive sleep apnea claims, because the Board is remanding the claims, 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).

Issue 1: Entitlement to service connection for diabetes mellitus

Service Connection - Secondary

Service connection on a secondary basis is merited if there is (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. Wallin v. West, 11?Vet.
strain with degenerative arthritis and obstructive sleep apnea claims, because the Board is remanding the claims, 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).

Issue 1: Entitlement to service connection for diabetes mellitus

Service Connection - Secondary

Merits

In November 2021, the Veteran first claimed service connection for diabetes mellitus as secondary to his service-connected tinnitus. In February 2022, the AOJ denied the claim without examining him. In turn, this set in motion a series of events in which the Veteran continuously pursued his November 2021 claim under 38 C.F.R. § 3.2500. Ultimately, this continuous pursuit resulted in an October 16, 2023 rating decision, for which the AOJ notified the Veteran on October 17, 2023.

On August 29, 2024, the Veteran again claimed service connection for diabetes mellitus as secondary to his service-connected tinnitus. See VA Form 21-526EZ. The AOJ rejected this claim as having been filed on an improper VA form, so the Veteran filed the claim again, but this time on a VA Form 20-0995 on November 19, 2024.

Pursuant to Chisholm v. Collins, 38 Vet. App. 140 (2025), the Board construes the Veteran's August 29, 2024 claim for service connection for diabetes mellitus as a valid supplemental claim in response to the October 2023 rating decision. Because he filed it within one year of October 17, 2023, the date the AOJ notified him of the October 16, 2023 rating decision, the Board finds he has continuously pursued his November 2021 claim.

In the March 2025 rating decision on appeal, the AOJ found the Veteran had a current disability, i.e., diabetes mellitus, and a primary service-connected disability, i.e., tinnitus, but it denied the claim based on no medical nexus. Because medical nexus is the only outstanding element in the Veteran's claim, the Board will focus on this.

This appeal turns on the third element of his secondary service connection claim, i.e., medical nexus. The AOJ did not examine him after his 2024 claim. Instead, it relied upon the VA opinions already in the record.

In November 2021, the Veteran submitted medical articles which state that the diabetic population is in a high-risk group for auditory complications. This suggests the diabetes mellitus may lead to tinnitus, not that tinnitus leads to diabetes mellitus.

In August 2022, the AOJ examined him. The examiner opined that the Veteran's tinnitus did not cause his CKD: "The conditions of diabetes mellitus and tinnitus are not medically related. The disability is a separate entity entirely from the tinnitus and unrelated to it. A thorough review of evidence-based peer-reviewed medical literature failed to demonstrate a causal relationship. Therefore, the claim diabetes mellitus condition is less likely than not (less than 50 percent probability) proximately due to the service-connected tinnitus. A nexus has not been established." The examiner did not opine whether the Veteran's tinnitus aggravates his diabetes mellitus.

In September 2023, the AOJ obtained an addendum opinion. For secondary causation, the clinician opined: "The claimed condition is less likely than not (likelihood is less than approximately balanced or nearly equal) proximately due to or the result of the veteran's service connected condition of TINNITUS. Rationale is available medical literature fails to support a pathophysiological relationship between veteran's service-connected Tinnitus and diagnosed Diabetes as these conditions are separate systems. Medical literature notes that Diabetes mellitus refers to a group of diseases that affect how the body uses blood sugar (glucose). Glucose is an important source of energy for the cells that make up the muscles and tissues. It's also the brain's main source of fuel. The main cause of diabetes varies by type. But no matter what type of diabetes you have, it can lead to excess sugar in the blood. Too much sugar in the blood can lead to serious health problems (source:https://www.may
connected condition of TINNITUS. Rationale is available medical literature fails to support a pathophysiological relationship between veteran's service-connected Tinnitus and diagnosed Diabetes as these conditions are separate systems. Medical literature notes that Diabetes mellitus refers to a group of diseases that affect how the body uses blood sugar (glucose). Glucose is an important source of energy for the cells that make up the muscles and tissues. It's also the brain's main source of fuel. The main cause of diabetes varies by type. But no matter what type of diabetes you have, it can lead to excess sugar in the blood. Too much sugar in the blood can lead to serious health problems (source:https://www.mayoclinic.org/diseases-conditions/diabetes/symptoms-causes/syc-20371444. As such a nexus could not be established."

For secondary aggravation, the clinician opined: "The claimed condition is less likely than not (likelihood is less than approximately balanced or nearly equal) proximately due to or the result of the veteran's service connected condition of TINNITUS. Rationale is available medical literature fails to support a pathophysiological relationship between veteran's service-connected Tinnitus and diagnosed [diabetes mellitus] as these conditions are separate systems. Medical literature notes that Diabetes mellitus refers to a group of diseases that affect how the body uses blood sugar (glucose). Glucose is an important source of energy for the cells that make up the muscles and tissues. It's also the brain's main source of fuel. The main cause of diabetes varies by type. But no matter what type of diabetes you have, it can lead to excess sugar in the blood. Too much sugar in the blood can lead to serious health problems (source:https://www.mayoclinic.org/diseases-conditions/diabetes/symptoms-causes/syc-20371444. As such a nexus could not be established."

The Board finds these opinions, when viewed collectively, effectively address the secondary service connection inquiry and assigns them great probative value. Neither the Veteran nor his representative have contested the adequacy of these opinions, nor have they identified any error in the AOJ's decision. Accordingly, the Board finds the Veteran has not satisfied the third element of his secondary service connection claim.

Because the Veteran has not satisfied all three elements of his secondary service connection claim, the evidence is persuasively against the claim, and the Board denies the appeal under a secondary theory of entitlement.

Issue 2: Entitlement to service for chronic kidney disease

Merits

In November 2021, the Veteran first claimed service connection for chronic kidney disease as secondary to his service-connected tinnitus. In February 2022, the AOJ denied the claim without examining him. In turn, this set in motion a series of events in which the Veteran continuously pursued his November 2021 claim under 38 C.F.R. § 3.2500. Ultimately, this continuous pursuit resulted in an October 16, 2023 rating decision, for which the AOJ notified the Veteran on October 17, 2023.

On August 29, 2024, the Veteran again claimed service connection for chronic kidney disease as secondary to his service-connected tinnitus. See VA Form 21-526EZ. The AOJ rejected this claim as having been filed on an improper VA form, so the Veteran filed the claim again, but this time on a VA Form 20-0995 on November 19, 2024.

Pursuant to Chisholm v. Collins, 38 Vet. App. 140 (2025), the Board construes the Veteran's August 29, 2024 claim for service connection for chronic kidney disease as a valid supplemental claim in response to the October 2023 rating decision. Because he filed it within one year of October 17, 2023, the date the AOJ notified him of the October 16, 2023 rating decision, the Board finds he has continuously pursued his November 2021 claim.

In the March 2025 rating decision on appeal, the AOJ found the Veteran had a current disability, i.e., chronic kidney disease, and a primary service-connected disability, i.e., tinnitus, but it denied the claim based on no medical nexus. Because medical nexus is the only outstanding element in the Veteran's claim, the Board will focus on this.

In November 2021, the Veteran submitted a medical
Board finds he has continuously pursued his November 2021 claim.

In November 2021, the Veteran submitted a medical article which concerns chronic kidney disease and an increased risk of sudden sensorineural hearing loss and Meniere's disease, disabilities which are not service-connected. Indeed, it suggests that the chronic kidney disease population is in a high-risk group for auditory complications, i.e., chronic kidney disease may lead to sensorineural hearing loss and Meniere's disease, not the other way around. Moreover, the article does not reference tinnitus.

In August 2022, the AOJ examined him. The examiner opined that the Veteran's tinnitus did not cause his CKD: "The conditions of chronic kidney disease and tinnitus are not medically related. The disability is a separate entity entirely from the tinnitus and unrelated to it. A thorough review of evidence-based peer-reviewed medical literature failed to demonstrate a causal relationship. Therefore, the claimed chronic kidney disease condition is less likely than not (less than 50 percent probability) proximately due to the service-connected tinnitus. A nexus has not been established." The examiner did not opine whether the Veteran's tinnitus aggravates his chronic kidney disease.

For secondary aggravation, the clinician opined: "The claimed condition was less likely than not aggravated beyond its natural progression by the veteran's service connected condition. Rationale is available medical literature fails to support a pathophysiological relationship between veteran's service-connected Tinnitus and diagnosed chronic kidney disease as these conditions are separate systems. Veteran 10/27/2020 exam noted ([E.S.], MA; 10/27/2020 2:18 PM Stage 3 chronic kidney disease due to benign hypertension (112.9). Thus, available evidence supports veteran chronic kidney disease is directly as a result of benign hypertension."

REASONS FOR REMAND

Background Law

Under the AMA, the Board may only remand an issue for the correction of (1) duty to assist errors occurring prior to the date of the AOJ decision on appeal (i.e., pre-decisional duty to assist errors) and (2)?AOJ errors in satisfying a regulatory or statutory duty, if correction of such error would have a reasonable possibility of aiding in substantiating the appellant's claim. ?See?38?C.F.R. §?20.802(a).?

Issue 3: Entitlement to service connection for a lumbosacral strain with degenerative arthritis

As background, the Veteran first claimed compensation for a low back disorder in February 2007. The AOJ denied the claim in December 2007. In turn, this set in motion a series of claims and decisions, with the latter including denials in May 2014, December 2017, July 2020, April 2021, and
and (2)?AOJ errors in satisfying a regulatory or statutory duty, if correction of such error would have a reasonable possibility of aiding in substantiating the appellant's claim. ?See?38?C.F.R. §?20.802(a).?

Issue 3: Entitlement to service connection for a lumbosacral strain with degenerative arthritis

Additionally, the AOJ examined him for these claims in May 2014 and November 2017.

In May 2014, the VA examiner opined: "Veteran does not have a current diagnosis of lumbar strain. His current diagnosis is DJD lumbosacral spine. Review of STRS indicate that the veteran had lumbar strain during service in 1976. In my opinion, lumbar strain is less likely than not incurred in or caused by (the) lumbar strain noted (July 1976) during service. Rationale is that there is no diagnosis of lumbar strain. Moreover, there is no documentation of Veteran receiving treatment for back condition following discharge for over 10 years. Therefore, his current back condition is related to factors other than service."

In November 2017, the VA examiner opined: "Veteran had treatment for acute low back pain in 1976. Radiology including myelogram and X-ray were normal. Following this, there are no available records for many years after service. He has had a lifetime to develop arthritis which is a common finding in the low back. It is less likely than not that the Veteran's low back strain diagnosed on active duty is related to his current lumbosacral strain and Low Back Condition To Include Ls-S1 Narrowing Of Disc Height, L5-S1 Facet Joint Degenerative Changes, And L4-L5 Facet Joint Degenerative Changes. Veteran's service treatment records from 01/23/2014 and private treatment records from 11/07/2017 have been reviewed."

In the March 2025 rating decision on appeal, the AOJ found the Veteran had submitted new and relevant evidence to warrant readjudicating his claim. Also, the AOJ found the Veteran had a current disability (lumbosacral strain with degenerative arthritis) and an in-service event ("Your service treatment records show complaints of lower back pain in 1976."), but it denied the claim based on no medical nexus. It did not examine him prior to denying his most recent claim.

The Board finds remand is warranted. The AOJ relied on the two VA opinions of record. However, neither addresses his contention of continuous symptoms since service. For example at the November 2017 examination, the examiner reported: "Veteran relates that while on active duty, he worked in base supply. He reports he did heavy lifting. He relates he was seen on active duty for complaints of back pain. He relates he did some therapy on his back and took some medication. Veteran's condition has worsened over time. He says, 'the older I get, the worse this gets.'" Because the AOJ relied on opinions which do not address his contention of continuous symptoms since service, the Board finds the AOJ erred by not examining him before deciding his claim. Accordingly, the Board will remand for it to do so.

Issue 4: Entitlement to service connection for obstructive sleep apnea

In March 2019, the Veteran claimed service connection for obstructive sleep apnea under a direct theory of entitlement due to "working inventory."

In December 2019, the AOJ denied the claim without examining him. It found he did not have a current disability, in-service event, or a medical nexus to service.

In July 2020, the Veteran claimed service connection for obstructive sleep apnea, but he did not specify on what basis.

Later that month, the AOJ found the Veteran had submitted new and relevant evidence to warrant readjudicating the claim. It found he had a current disability, but it denied the claim based on no in-service event and no medical nexus to service.

In January 2021, the Veteran claimed service connection for obstructive sleep apnea, but he did not specify on what basis.

In April 2021, the AOJ found the Veteran had submitted new and relevant evidence to warrant readjudicating the claim. It found he had
-service event, or a medical nexus to service.

In July 2020, the Veteran claimed service connection for obstructive sleep apnea, but he did not specify on what basis.

In January 2021, the Veteran claimed service connection for obstructive sleep apnea, but he did not specify on what basis.

In April 2021, the AOJ found the Veteran had submitted new and relevant evidence to warrant readjudicating the claim. It found he had a current disability, but it denied the claim based on no in-service event and no medical nexus to service.

In November 2021, the Veteran claimed service connection for obstructive sleep apnea, as secondary to service-connected tinnitus. With his claim, he submitted a) an article relating obstructive sleep apnea to tinnitus, and b) a generic medical nexus opinion from a VA-accredited attorney's website relating obstructive sleep apnea to tinnitus (https://danaise.com/tinnitus-causes-sleep-apnea/.)

In December 2021, the AOJ examined him. The examiner reported the Veteran dated onset in 1975 as he "started to notice that he would stop breathing in his sleep." For secondary causation, the examiner opined: "There is no medical basis for the VETERAN'S TINNITUS to cause his claimed OBSTRUCTIVE SLEEP APNEA. No such direct causal relationship exists." The examiner did not opine whether the Veteran's tinnitus aggravates his obstructive sleep apnea.

In February 2022, the AOJ found the Veteran had submitted new and relevant evidence to warrant readjudicating the claim. It found he had a current disability, i.e., obstructive sleep apnea, and a primary service-connected disability, i.e., tinnitus, but it denied the claim based on no medical nexus.

In March 2022, the Veteran requested an HLR of the February 2022 rating decision.

In April 2022, the AOJ found it erred in the February 2022 rating decision as it failed to obtain the Veteran's personnel records and active-duty service treatment records. It did not order an opinion.

In September 2022, the AOJ denied the claim. It found he had a current disability, i.e., obstructive sleep apnea, and a primary service-connected disability, i.e., tinnitus, but it denied the claim based on no medical nexus.

In October 2022, the Veteran requested an HLR of the September 2022 rating decision.

In December 2022, the AOJ found it erred in the September 2022 rating decision as it a) failed to attempt to obtain private treatment records and b) had not completed the development for the Veteran's active-duty service treatment records.

In December 2023, the AOJ obtained an opinion. It erroneously stated there was in-service evidence of sleep apnea. The clinician identified this error: "THE VETERAN'S CLAIMED OBSTRUCTIVE SLEEP APNEA IS/ARE LESS LIKELY THAN NOT (LESS THAN 50 PERCENT PROBABILITY) INCURRED IN OR CAUSED BY THE OBSTRUCTIVE SLEEP APNEA DURING SERVICE. The Veteran's active duty medical records are silent for OBSTRUCTIVE SLEEP APNEA DURING SERVICE."

In January 2024, the AOJ denied the claim on both direct and secondary theories of entitlement. For direct, it found he had a current disability, but it denied the claim based on no in-service event and no medical nexus to service. For secondary, it found he had a current disability, i.e., obstructive sleep apnea, and a primary service-connected disability, i.e., tinnitus, but it denied the claim based on no medical nexus.

In November 2024, the Veteran claimed service connection for obstructive sleep apnea, but he did not specify a theory.

In the March 2025 rating decision on appeal, the AOJ found the Veteran had submitted new and relevant evidence to warrant readjudicating the claim. Also, it denied only on a direct theory of entitlement. In so doing, it found he had a current disability, but it denied the claim based on no in-service event and no medical nexus to service. It did not address secondary service connection.

In his January 2026 appeal, the Veteran pivoted to another theory of secondary entitlement: that his service-connected gastroesophageal reflux disease (GERD) either caused or aggravates his obstruct
November 2024, the Veteran claimed service connection for obstructive sleep apnea, but he did not specify a theory.

The Board finds remand is warranted because no clinician has opined on the Veteran's November 2021 submissions, to include the generic nexus opinion he submitted. Because the AOJ did not obtain an addendum opinion to consider these submissions before deciding the claim, it erred. Remand is thus warranted for it to do so.

Relatedly, because neither the Veteran nor the record raised the secondary theory of entitlement vis-à-vis GERD until after the rating decision on appeal, the Board finds the AOJ did not err in not developing this theory. However, it should consider this theory upon remand. Also, nothing indicates David Anaise, the VA accredited attorney from whose website the Veteran copied the generic nexus opinion, has any relationship, i.e., medical, legal, or otherwise, with the Veteran. Therefore, the Board finds the medical nexus opinion he submitted in November 2021 has no probative value.

The matters are REMANDED for the following action:

1. Schedule the Veteran for an examination to determine the nature and etiology of his lumbosacral strain with degenerative arthritis. The clinician must review the claims file including this Remand. The clinician must opine:

a) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's lumbosacral strain with degenerative arthritis began during, or was otherwise caused by, his military service? Why or why not?

In answering question (a), the clinician must expressly address the Veteran's contention that he has experienced continuous symptoms since service.

A complete rationale is required for all opinions.

2. Obtain and addendum medical opinion to determine the nature and etiology of the Veteran's obstructive sleep apnea. The clinician must review the claims file including this Remand. The clinician must opine:

a) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's service-connected tinnitus CAUSED the Veteran's obstructive sleep apnea? Why or why not?

b) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's service-connected tinnitus AGGRAVATES the Veteran's obstructive sleep apnea? Why or why not?

In answering questions (a) and (b), the clinician should address the articles the Veteran submitted in November 2021 as well as the generic nexus opinion.

In answering question (b) regarding aggravation, the clinician is reminded that aggravation is defined as any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury. The clinician is advised that finding that the Veteran's obstructive sleep apnea was aggravated due to a service-connected disability does not require evidence of permanent worsening and may encompass any additional impairment in earning capacity resulting from an already service-connected condition.

A complete rationale is required for all opinions.

Tiffany Dawson

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board M. Sopko, Counsel

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.

Analyze in VA Law Explorer