Citation Nr: 1337096 Decision Date: 11/14/13 Archive Date: 11/26/13 DOCKET NO. 07-02 331 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for coronary artery disease and hypertension, status post pacemaker implant and aortic valve replacement, to include as secondary to exposure to non-ionizing radiation. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARINGS ON APPEAL Appellant and Spouse ATTORNEY FOR THE BOARD T. L. Douglas, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from March 1963 to March 1965. This matter comes before the Board of Veterans' Appeals (Board) by order of the United States Court of Appeals for Veterans Claims (hereinafter "the Court") in November 2012, which granted an unilateral motion for vacatur and remand vacating a June 2012 Board decision and remanded the issue on appeal for additional development. The Court had previously granted a joint motion for remand in June 2011 vacating a November 2010 Board decision. The appeal arose from a June 2005 rating decision on behalf of the St. Petersburg, Florida, Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran testified at personal hearings before two of the undersigned Veterans Law Judges. Copies of the transcripts of those hearings are of record. The issue on appeal was adequately explained to him and the submission of evidence which he may have overlooked and which would be advantageous to his position was suggested. See 38 C.F.R. § 3.103(c) (2012). In correspondence dated in September 2013 the Veteran waived his right to appear at an additional hearing before the third Veterans Law Judge assigned to decide his appeal. FINDING OF FACT Coronary artery disease and hypertension were not manifest during active service or within the first post-service year, are not diseases for presumptive service connection for a radiation-exposed veteran nor radiogenic diseases for VA compensation purposes, and are not shown to have developed as a result of an established event, injury, or disease during active service. CONCLUSION OF LAW Coronary artery disease and hypertension are not incurred in or aggravated by service nor may service connection be presumed as a result of ionizing radiation exposure. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309. 3.311 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The Veteran was notified of the duties to assist and of the information and evidence necessary to substantiate his claim by correspondence dated in September 2004. The notice requirements pertinent to the issue on appeal have been met and all identified and authorized records relevant to the matter have been requested or obtained. The available record includes service medical records, VA treatment, examination, and examination addendum reports, private treatment records and medical opinions, internet source information provided by the Veteran in September 2004 and May 2006, a medical literature summary provided by the Veteran in July 2009, and statements and testimony in support of the claim. The development requested on remand in April 2008, August 2009, June 2010, and December 2011 has been substantially completed. There is no evidence of any additional existing pertinent records. In correspondence dated in May 2013 the Veteran reported that he had no additional evidence to submit in support of his claim. The Board finds that further attempts to obtain additional evidence would be futile. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). When VA undertakes to provide a VA examination or obtain a VA opinion it must ensure that the examination or opinion is adequate. VA medical opinions obtained in this case are adequate as they are predicated on a substantial review of the record and medical findings and consider the Veteran's complaints and symptoms. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion as to the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4) (2012). The available medical evidence is sufficient for an adequate determination. There has been substantial compliance with all pertinent VA law and regulations and to adjudicate the claim would not cause any prejudice to the appellant. Service Connection Service connection may be granted for a disability resulting from injury suffered or disease contracted in line of duty or for aggravation of preexisting injury suffered or disease contracted in line of duty. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Where a Veteran is seeking service connection for any disability, due consideration shall be given to the places, types, and circumstances of the Veteran's service as shown by the veteran's service record, the official history of each organization in which the Veteran served, the Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a) (West 2002). Service connection can be granted for certain chronic diseases, including cardiovascular-renal diseases, if manifest to a degree of 10 percent or more within one year of separation from active service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Diseases specific to radiation-exposed Veterans shall be presumed to have been incurred in service for radiation-exposed Veterans. That presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). The term radiation-exposed veteran means either a veteran who while serving on active duty, or an individual who while a member of a reserve component of the Armed Forces during a period of active duty for training or inactive duty training, participated in a radiation-risk activity. 38 C.F.R. § 3.309(d)(3)(i) (2012). Diseases presumptively service connected for radiation-exposed veterans under the provisions of 38 U.S.C.A. § 1112(c) and 38 C.F.R. § 3.309(d)(2) are: Leukemia (other than chronic lymphocytic leukemia), cancer of the thyroid, cancer of the breast, cancer of the pharynx, cancer of the esophagus, cancer of the stomach, cancer of the small intestine, cancer of the pancreas, multiple myeloma, lymphomas (except Hodgkin's disease), cancer of the bile ducts, cancer of the gallbladder, primary liver cancer (except cirrhosis or hepatitis B as indicated), cancer of the salivary glands, cancer of the urinary tract; bronchiolo-alveolar carcinoma; cancer of the bone; cancer of the brain; cancer of the colon; cancer of the lung; and cancer of the ovary. 38 U.S.C.A. § 1112(c)(2) (West 2002); 38 C.F.R. § 3.309(d) (2012). In claims involving radiation exposure in which a radiogenic disease first became manifest after service and not manifest to a compensable degree within any applicable presumptive period, an assessment will be made as to the size and nature of the radiation dose or doses. 38 C.F.R. § 3.311(a)(1) (2012). If a claimant does not qualify as a "radiation-exposed veteran" under 38 C.F.R. § 3.303(d)(3) or does not have one of the presumptive diseases listed in 38 C.F.R. § 3.309(d)(2), the development procedures provided in 38 C.F.R. § 3.311 may apply if a veteran has a radiogenic disease and claims exposure to ionizing radiation in service. "Radiogenic disease" means a disease that may be induced by ionizing radiation and include the following: (i) All forms of leukemia except chronic lymphatic (lymphocytic) leukemia; (ii) thyroid cancer; (iii) breast cancer; (iv) lung cancer; (v) bone cancer; (vi) liver cancer; (vii) skin cancer; (viii) esophageal cancer; (ix) stomach cancer; (x) colon cancer; (xi) pancreatic cancer; (xii) kidney cancer; (xiii) urinary bladder cancer; (xiv) salivary gland cancer; (xv) multiple myeloma; (xvi) posterior subcapsular cataracts; (xvii) nonmalignant thyroid nodular disease; (xviii) ovarian cancer; (xix) parathyroid adenoma; (xx) tumors of the brain and central nervous system; (xxi) cancer of the rectum; (xxii) lymphomas other than Hodgkin's disease; (xxiii) prostate cancer; and (xxiv) any other cancer. 38 C.F.R. § 3.311(b)(2). When a claim is based on a disease other than one of those listed in 38 C.F.R. § 3.311(b)(2), VA shall consider the claim under the provisions of 38 C.F.R. § 3.311 provided that the claimant has cited or submitted competent scientific or medical evidence that the claimed condition is a radiogenic disease. 38 C.F.R. § 3.311(b)(4) (2012). Even though a disease is not included on the list of presumptive diseases, a nexus between the disease and service may nevertheless be established on the basis of direct service connection. Stefl v. Nicholson, 21 Vet. App. 120 (2007). When a claimed disorder is not included as a presumptive disorder, direct service connection may nevertheless be established by evidence demonstrating that the disease was in fact incurred during the service. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). For the showing of chronic disease in service, there are required a combination of manifestations sufficient to identify a disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). Continuity of symptomatology applies to those conditions explicitly recognized as chronic. 38 C.F.R. § 3.309(a) (2012); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In order to prevail on the issue of service connection on the merits, there must be medical evidence of (1) a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247 (1999). A veteran seeking disability benefits must establish the existence of a disability and a connection between service and the disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). Medical evidence is required to demonstrate a relationship between a current disability and the continuity of symptomatology demonstrated if the condition is not one where a lay person's observations would be competent. Clyburn v. West, 12 Vet. App. 296 (1999). Whether lay evidence is competent and sufficient in a particular case is an issue of fact and lay evidence can be competent and sufficient to establish a diagnosis when (1) a layperson is competent to identify the medical condition (sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Lay evidence presented by a Veteran concerning his continuity of symptoms after service may be considered credible, and ultimately competent, regardless of a lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (2006). The Board has the authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 C.F.R. § 3.102 (2012). In this case, the Veteran essentially contends that his coronary artery disease and hypertension, status post pacemaker implant and aortic valve replacement, is the result of exposure to radiation while in the military. He reported he was a generator mechanic repairing diesel equipment and that he worked in close proximity to Hawk missiles. He also reported that the generators were needed to run the radar site and that he was exposed to electromagnetic radiation from the generators. He further indicated that the radar was on all of the time. He reported that he was exposed to radar from three batteries which were 50 yards apart and that he was placed in the middle of them. He testified that he was trained on Nike Hercules missiles where he was exposed to radar. It is his contention that these exposures caused his current coronary artery disease and hypertension, status post pacemaker implant and aortic valve replacement. In testimony provided in support of his claim the Veteran, in essence, denied having had atomic or ionizing radiation exposure during active service. In correspondence dated in May 2005 he reported that his hypertension and heart problems began approximately three or four years after his separation from active service. The Veteran's service medical records are negative for diagnosis or treatment for coronary artery disease or hypertension. His DD Form 214 reflects that his primary specialty was power generator specialist. Private medical records dated in August 1985 noted a one year history of hypertension. A diagnosis of mild essential hypertension was provided. Subsequent records note diagnoses of coronary artery disease and hypertension, status post pacemaker implant and aortic valve replacement, without opinion as to etiology. In correspondence dated in March 2006 J.S.G., D.O., reported that the Veteran had been his patient for approximately one year. Dr. J.S.G. also stated that it was his opinion that it is more likely than not that his present condition was due to his exposure to electromagnetic radiation in service. At his VA examination in May 2009 the Veteran reported that he was started on medication for his hypertension in the early 1970's. He reported that he had been a generator mechanic for the Hawk missile system in the military. His medical history was documented and an examination was conducted. The examiner provided diagnoses of essential hypertension, coronary artery disease (CAD) with coronary artery bypass grafting (CABG), aortic valve replacement (AVR) secondary to aortic insufficiency, automatic implantable cardioverter defibrillator (AICD), and pacemaker. The examiner provided a literature review with references regarding electromagnetic radiation. The examiner also concluded that the results did not support the hypothesis of a link between occupational exposure to electromagnetic fields and an excess risk of severe cardiovascular arrhythmia leading to permanent implantation of a pacemaker. The examiner opined that the Veteran's hypertension, CAD, aortic valve disorder, and cardiac rhythm disorder did not have their onset in service or within one year of service. Rationale was provided and, as to hypertension, it was noted that the disorder was not noted in service and that there was no evidence hypertension occurred within one year of service. As to CAD, the examiner noted that there was no showing of CAD in service and that a diagnosis of CAD was not provided until 1999. As to the aortic valve abnormality, the examiner noted that there was no mention of the disorder in service and that the Veteran did not undergo AVR until 1999, years after service. As to the cardiac rhythm abnormality, the examiner noted that there was no problem in service and that the Veteran had an abnormal Holter in 2002 with the acute onset of bradycardia and fatigue. It was noted that this was acute with no indication of the disorder prior to 2002. The examiner further opined that the Veteran's essential hypertension and cardiac conduction abnormality requiring a pacemaker insertion were not caused by, a result of, or secondary to his exposure to electromagnetic radiation while in service. She stated that after careful review of the literature, she could see no definitive evidence of any etiological relationship. She further stated that she was not in agreement with the opinion provided in the March 2006 letter from Dr. J.S.G. She noted that Dr. J.S.G. was a family practice physician and that the case was discussed with a VA cardiology specialist whose opinion as to etiology was also not in agreement with the opinion of Dr. J.S.G. (Although the examiner reported that she saw definite evidence after careful review of the literature that CAD is caused by electromagnetic radiation, she provided a correction to this statement in a subsequent January 2012 addendum report.) In private medical correspondence dated in August 2009 A.B., M.D., stated he had reviewed the Veteran's records for hypertension, aortic valve replacement, pacemaker and implantable cardioverter defibrillator (ICD) and had reviewed the research depicting the effects of excessive radar and electromagnetic field to the body systems. He reported that the Veteran, having had such exposure for 18 months, 24 hours a day as a HAWK missile generator operator, could likely have had later onset health issues. He stated that he had examined the Veteran and conducted tests which demonstrated all conditions claimed. He reported that, based upon past records and no inherited factors, it was more likely than not these disorders were the result of his job environment while in the Army. He reported his contention that the amount of exposure to electromagnetic field and radar would take many years to damage the system. He noted that with hypertension starting in 1969, only 3 years after Army discharge, it more likely progressed to coronary artery disease. It was also noted that radiation could cause gradual system changes to the vascular system. In January 2012, an addendum opinion was obtained from the May 2009 VA examiner. It was noted that she had reviewed the claims file and the May 2009 examination reported and she clarified that her previous opinion as to CAD should have included a "no." The examiner stated that the Veteran's CAD was not caused by or a result of exposure to electromagnetic radiation while in service. She stated that she saw no definite evidence after a careful review of the literature that CAD is caused by electromagnetic radiation. She also, in essence, reasserted her opinion as to the findings of her literature review as provided in her May 2009 report. Based upon the evidence of record, the Board finds that the Veteran's coronary artery disease and hypertension were not manifest during active service or within the first post-service year, are not diseases for presumptive service connection for a radiation-exposed veteran nor radiogenic diseases for VA compensation purposes, and are not shown to have developed as a result of an established event, injury, or disease during active service. With respect to the question of whether presumptive service connection is warranted under the provisions applicable to chronic diseases, the Board finds there is no evidence of coronary artery disease or hypertension in service or within one year of separation and that the Veteran has not contended otherwise. The Veteran has also denied having any atomic or ionizing radiation exposure. Therefore, entitlement to service connection on a presumptive basis must be denied. As to the question of whether direct service connection for coronary artery disease and hypertension, status post pacemaker implant and aortic valve replacement, may be established, the Board finds the Veteran's statements as to generator and radar exposure are consistent with the circumstances of his service. The available medical evidence also includes diagnoses of coronary artery disease and hypertension, status post pacemaker implant and aortic valve replacement, with private medical opinions in March 2006 and August 2009, in essence, relating these medical disorders to electromagnetic field radiation. The Board finds, however, that the opinions of the May 2009 VA examiner, as clarified by her January 2012 addendum report, are persuasive in this case. The examiner is shown to have considered the evidence of record and to have provided adequate rationale for the etiology opinions provided. She is also shown to have adequately considered the Veteran's lay statements, the internet source and medical literature information provided by the Veteran, and the private medical opinions of record, but to have considered that evidence in light of additional relevant medical and scientific evidence. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). Treatise evidence may also suffice to establish nexus in instances where "standing alone, [it] discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion." Wallin v. West, 11 Vet. App. 509, 514 (1998); see also Hensley v. West, 212 F.3d 1255, 1265 (2000) ("A veteran with a competent medical diagnosis of a current disorder may invoke an accepted medical treatise in order to establish the required nexus; in an appropriate case it should not be necessary to obtain the services of medical personnel to show how the treatise applies to his case."). The Court has held that medical articles or treatises can provide important support when combined with an opinion of a medical professional if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion. See Mattern v. West, 12 Vet. App. 222 (1999); see also Sacks v. West, 11 Vet. App. 314 (1998) (noting that treatise materials generally are not specific enough to show nexus); Herlehy v. Brown, 4 Vet. App. 122, 123 (1993) (noting that medical opinions directed at specific patients generally are more probative than medical treatises). The Board finds that the internet source and medical literature summary information provided by the Veteran in this case is not sufficient to establish service connection and that the May 2009 VA examiner has identified subsequently dated studies which, in essence, refuted earlier studies associating medical disorders to electromagnetic field exposure. The Board notes that "the Court has expressly declined to adopt a 'treating physician rule' which would afford greater weight to the opinion of a veteran's treating physician over the opinion of a VA or other physician." Winsett v. West, 11 Vet. App. 420, 424-25 (1998) (citing Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also Williams v. Brown, 4 Vet. App. 270, 273 (1993) ("Nowhere is it provided in law or regulation that opinions by the examining psychiatrists are inherently more persuasive than that of other competent mental health professionals."). The Court has held, however, that "[a] private medical opinion may not be discounted solely because the opining physician did not review the claims file." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Further, "the Board may not prefer a VA medical opinion over a private medical opinion solely because the VA examiner reviewed the claims file." Id. The level of training, education, and experience of the person conducting the examination is a factor that, if the Board affords more or less weight to the report because of that reason, must be thoroughly explained in its decision. Cox v. Nicholson, 20 Vet. App. 563, 569 (2007) (citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996), but superseded by statute for an unrelated point of law as stated by Duenas v. Principi, 18 Vet. App. 512 (2004)). In determining whether evidence is credible VA may consider internal consistency, facial plausibility, and consistency with other evidence. See Caluza, 7 Vet. App. at 511; see also Buchanan, 451 F.3d at 1337 (VA can consider bias in lay evidence and conflicting statements of the veteran in weighing credibility); Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor); Pond v. West, 12 Vet. App. 341, 345 (1999) (holding in a case where the claimant was also a physician, and therefore a medical expert, that the Board should properly consider the appellant's own personal interest in the outcome of the case). The Board notes that, in this case, the March 2006 opinion of Dr. J.S.G. did not identify any specific medical disorder and provided no rationale for the opinion provided. Therefore, the opinion is found to be of no probative weight as to the issue on appeal. As to the August 2009 opinion of Dr. A.B. which identified hypertension and heart-related disorders as related to the Veteran's environment in service, the Board finds that while it was noted that research depicting the effects of excessive radar and electromagnetic field to the body systems had been reviewed the specific material reviewed was not identified. Although the August 2009 statement, in essence, appears to draw a comparison between electromagnetic field radiation and Agent Orange exposure, no supporting rationale was provided as to this association and the use of the term "could" by Dr. A.B. renders this part of the statement too equivocal to be of any probative weight. For these reasons, the nexus opinion of Dr. A.B. is found to be of a lesser degree of probative weight than the opinions of the May 2009 VA examiner. The Board further finds that as Dr. A.B. provided no specific rationale nor reference to medical or scientific study in support of the provided opinion the failure of the January 2012 VA addendum to address it does not render the addendum opinion inadequate. In fact, without reference to specific medical or scientific study or other medical rationale in the August 2009 statement the January 2012 addendum could not have adequately reconciled the examiner's review of the literature with the August 2009 opinion. Further, the Board finds that the rationale provided for the August 2009 opinion is shown to have been based, at least in part, on a finding that the Veteran's hypertension began in 1969. Records, however, in the file include private treatment records demonstrating that the Veteran's hypertension was first manifest in 1984. As the 1985 treatment report was provided during the course of treatment the Board finds it is persuasive as to the date of onset. The Veteran's subsequent reports of an onset of hypertension in 1969 are found to be inconsistent with his private treatment records and to be not credible due to his interests in the outcome of this claim. The Board finds the date of onset for hypertension provided in the August 2009 opinion was based upon a history provided by the Veteran that is not credible based upon the evidence of record. Therefore, the medical opinion as to this matter or to the extent it was based upon that reported history is also not credible. The Court has held that evidence which is simply information recorded by a medical examiner, unenhanced by any additional medical comment by that examiner, does not constitute competent medical evidence. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). Additionally, a "[Doctors'] diagnoses can be no better than the facts alleged by appellant." Swann v. Brown, 5 Vet. App. 229, 233 (1993). The Board further finds that the Veteran is competent to provide evidence as to observations and some medical matters, but that his statements are, at most, conclusory assertions of a nexus between his present disabilities and service. Jandreau, 492 F.3d 1372; Buchanan, 451 F.3d 1331. As questions of medical diagnosis and a relationship to service are complex etiological questions akin to the type of medical matters which laypersons are not competent to provide, his statements are insufficient to establish service connection. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (Board must determine whether claimed disability is type of disability for which lay person is competent to provide etiology or nexus evidence). Therefore, the claim for entitlement to service connection must be denied. When all the evidence is assembled VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The preponderance of the evidence in this case is against the claim. ORDER Entitlement to service connection for coronary artery disease and hypertension, status post pacemaker implant and aortic valve replacement, to include as secondary to exposure to non-ionizing radiation, is denied. F. JUDGE FLOWERS STEPHEN L. WILKINS Veterans Law Judge Veterans Law Judge Board of Veterans' Appeals Board of Veterans' Appeals _________________________________________________ ROBERT E. SULLIVAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs