Citation Nr: 1709396 Decision Date: 03/27/17 Archive Date: 04/07/17 DOCKET NO. 06-07 058 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to service connection for diabetes mellitus, to include as due to exposure to herbicides. 3. Entitlement to service connection for residuls of a right foot injury. 4. Entitlement to service connection for kidney failure, to include as secondary to hypertension and/or medications taken for service connected gastroesophageal reflux disease (GERD). 5. Entitlement to service connection for gastroparesis as secondary to GERD. 6. The propriety of the reduction for GERD with hiatal hernia and past history of duodenal ulcers, from 30 percent disabling to 10 percent disabling effective December 1, 2014. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran and his spouse and son ATTORNEY FOR THE BOARD M. Prem, Counsel INTRODUCTION The Veteran served on active duty from May 1973 to May 1975; and from August 1975 to January 1979. This matter comes to the Board of Veterans' Appeals (Board) on appeal from May 2004, June 2011, and September 2014 rating decisions by a Regional Office (RO) of the Department of Veterans Affairs (VA). The issues of entitlement to service connection for diabetes mellitus and a right foot disability were remanded in September 2007, August 2008, and June 2010 for further development. The issue of entitlement to service connection for hypertension was denied by the Board in September 2007. In October 2009, the United States Court of Appeals for Veterans Claims (Court) vacated the Board's decision. The issue was remanded in August 2008, and June 2010 for further development. The issues of entitlement to service connection for kidney disease, gastroparesis, and the propriety in reducing the Veteran's rating for GERD come to the Board of Veterans' Appeals (Board) on appeal from June 2011 and September 2014 rating decisions by a Regional Office (RO) of the Department of Veterans Affairs (VA). Notices of disagreement were received in July 2011, October 2014, and December 2014; statements of the case were issued in August 2011 and October 2015; and substantive appeals were received in August 2011 and November 2015. The Veteran presented testimony at Board hearings in January 2007 and October 2016. A transcript of each of the hearing is associated with the Veteran's claims folder. The Board notes that the Veterans Law Judge that conducted the January 2007 hearing is no longer with the Board. The Veteran was informed that he was entitled to a new hearing; but in December 2016, he declined. The RO denied a claim for a total disability rating based on individual unemployability (TDIU) in June 2013. The Veteran failed to file a timely notice of disagreement or re-raise the issue via statements or evidence. Consequently, the Board finds that this matter is not currently before it. The issue of entitlement to service connection for a kidney disability, to include as secondary to hypertension and/or medications taken for service connected GERD is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. Hypertension was not manifested during the Veteran's active duty service or for many years after service, nor is it otherwise related to service. 2. The Veteran did not serve in the Republic of Vietnam while on active duty; therefore, exposure to an herbicide agent is not presumed. 3. Diabetes was not manifested during the Veteran's active duty service or for many years after service, nor is it otherwise related to service to include as due to claimed exposure to herbicide agents during service. 4. The evidence in equipoise as to whether the Veteran's residuals of a right foot injury, to include scarring, are related to service. 5. Gastroparesis was not manifested during the Veteran's active duty service or for many years after service, and it is not otherwise related to service, nor is it secondary to service-connected GERD. 6. The 30 percent rating for the Veteran's GERD was in effect for more than five years at the time of the reduction. 7. The 2012 VA examination report on which the reduction was based did not reflect a material improvement in the Veteran's GERD or that it was reasonably certain that any improvement would be maintained under the ordinary conditions of life. CONCLUSIONS OF LAW 1. The criteria for an award of service connection for hypertension have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.6, 3.159, 3.303, 3.307, 3.309 (2016). 2. The criteria for an award of service connection for diabetes, to include as due to herbicide exposure, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.6, 3.159, 3.303, 3.307, 3.309 (2016). 3. The criteria for an award of service connection for a right foot disability have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.6, 3.159, 3.303 (2016). 4. The criteria for an award of service connection for gastroparesis have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.6, 3.159, 3.303, 3.310 (2016). 5. The RO's reduction of the rating for GERD from 30 to 10 percent was not in accordance with the applicable regulation; the criteria for restoration of the 30 percent rating have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.105, 3.344 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) In August 2003, April 2007, November 2007, January 2009, August 2011, and April 2012 letters, the RO satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2014) and 38 C.F.R. § 3.159(b) (2016). The RO notified the Veteran of: information and evidence necessary to substantiate the claims; information and evidence that VA would seek to provide; and information and evidence that he she was expected to provide. The Veteran was informed of the process by which initial disability ratings and effective dates are assigned, as required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The "duty to assist" contemplates that VA will help a claimant obtain records relevant to the claim, whether or not the records are in Federal custody, and that VA will provide a medical examination when necessary to make a decision on the claim. 38 C.F.R. § 3.159 (2016). VA has done everything reasonably possible to assist the Veteran with respect to the claim for benefits in accordance with 38 U.S.C.A. § 5103A (West 2014) and 38 C.F.R. § 3.159(c) (2016). Relevant service treatment and other medical records have been associated with the claims file. The Veteran was given VA examinations in May 2007, October 2008, March 2011, July 2014, and February 2015 which are fully adequate. The Board notes that the VA did not provide the Veteran with a VA examination for the purposes of determining the etiology of his diabetes mellitus. However, the Board finds that an examination/opinion is not necessary. The Court, in McLendon v. Nicholson, 20 Vet. App. 79 (2006), stated that in disability compensation (service connection) claims, VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. See 38 U.S.C.A. § 5103A(d)(2)(B). The Court has held that 38 U.S.C.A. § 5103A(d)(2)(B) establishes a "low threshold" requirement for determining whether or not a medical nexus examination is warranted. Id. at 83. The standards of McLendon are not met in this case as the evidence of records fails to suggest that diabetes mellitus, first reported many years post service, had its onset in service or is otherwise related thereto. Indeed, the Board finds that the Veteran's statements alone about a relationship are insufficient to trigger VA's duty to assist. See Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (explaining that something more than an appellant's conclusory, generalized statement is needed to trigger VA's duty to assist by providing a medical nexus examination). In sum, the duties to notify and to assist have been met. Service Connection Applicable law provides that service connection will be granted if it is shown that the Veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as hypertension and diabetes mellitus, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The Board also notes that secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). Applicable law also provides that a Veteran who, during active service, served during a certain time period in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that he was not exposed to any such agent during service. 38 U.S.C.A. § 1116; see also Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). Regulations further provide, in pertinent part, that if a Veteran was exposed to an herbicide agent (such as Agent Orange) during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: Chloracne or other acneform disease consistent with chloracne; Hodgkin's disease; multiple myeloma; non- Hodgkin's lymphoma; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx, or trachea); Type II diabetes mellitus, and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). Hypertension The Veteran contends that his hypertension was incurred in military service. At his January 2007 hearing, he testified to having been monitored for hypertension prior to his discharge from service. Tr. at 6. However, service treatment records fail to show a diagnosis for hypertension. The Veteran's highest blood pressure readings occurred in May 1975 (at which point he was noted to have blood pressure readings of 128/92 and 132/84. An August 1975 physical examination report shows that the Veteran's blood pressure had decreased to 114/80. At his December 1978 separation examination, the Veteran did not report any problems with his blood pressure, which was measured at 108/78. No diagnosis of hypertension was given and the Veteran was found to be clinically normal upon discharge. The Veteran submitted a private treatment report dated May 1990. It reflects that the Veteran's blood pressure was 142/89 (VBMS, 6/12/07). Someone handwrote that this is a "record of high blood pressure before his diagnosis of diabetes in 1991." Post-service medical evidence includes private treatment records from the Cascades East Family Practice Center dated June 1999 to March 2003, and the Merle West Medical Center dated October 2001 to December 2002. Treatment records from the White City VA Medical Center (VAMC) dated September 2002 to August 2006 are also included. A June 1999 treatment report reflects that the Veteran did not have a diagnosis of hypertension at that time (but that he was on the high side of normal) (VBMS, 9/22/03, p. 20). A review of the treatment records show that the Veteran was first treated for hypertension the following month: July 1999 (VBMS, 9/22/03, p. 17); more than 20 years after discharge from service. From then on, treatment records show that the Veteran continued to receive treatment for his hypertension. In April 2008, the Veteran submitted a March 2008 statement from VA clinician, Dr. W.B.A., in which he stated "to whom it may concern, [the Veteran] did have hypertension (high blood pressure) even as far back as 1975 as a documented blood pressure of 128/92 showed." The statement was accompanied by a March 2008 statement from Dr. K.D.S., who treated the Veteran for chronic kidney disease and hypertension. Dr. K.D.S. stated that the Veteran "has long-standing hypertension dating back to at least May of 1975 when he had documented diastolic hypertension with a diastolic pressure of 92." (VBMS, 4/30/08). The Veteran underwent a VA examination in March 2011. The examiner reviewed the claims file in conjunction with the examination. The examiner noted that there is a May 2004 note from the Roseberg Renal Clinic stating that elevated blood pressures were first noted in the service in the 1970s; and that treatment of the elevated blood pressure readings did not start until 1990s. Upon examination, the Veteran's blood pressure was measured at 122/72, 126/70, and 122/73 (all within normal limits). The examiner opined that it was less likely than not that the Veteran's hypertension began during or was causally related to service. He explained that the Veteran had a single elevated blood pressure of 122/92 noted during active service. Three other blood pressure readings taken that same day were all normal. There were no other elevated blood pressure readings in the service treatment records. In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). In this case, the Veteran has satisfied the first element of service connection. Post service treatment records clearly reflect treatment for hypertension. In light of this and prior action by the Board and the Court, the Board finds that the evidence establishes a current hypertension disability. However, with regards to the second and third elements of service connection, the Veteran's claims falls short. As noted above, the service treatment records fail to reflect any findings attributed to hypertension. The Board notes that a single in-service elevated blood pressure reading does not constitute a diagnosis of hypertension. That is particularly true when all other blood pressure readings (including three readings taken on the same day) were all within normal limits. See 38 C.F.R. § 3.303(b) ("For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic.") . The Board recognizes that the Dr. K.D.S. and Dr. W.B.A. stated that the Veteran's hypertension dates back to 1975. However, this is simply not reflected in the record. Dr. K.D.S. and Dr. W.B.A. based their opinions solely on a single elevated blood pressure reading (a fact which was acknowledged by the March 2011 VA examiner). In light of this lack of inclusion of pertinent facts, the Board gives the opinions of Drs. K.D.S. and W.B.A. little to no weight. The Board finds that a preponderance of the evidence is against a finding that the Veteran incurred hypertension during service or that he had chronic hypertension during service. Finally, with regards to the third element of service connection, the Board notes that there are conflicting opinions as to whether the Veteran's hypertension began during or is due to service. The Court has held that the Board must determine how much weight is to be attached to each medical opinion of record. See Guerrieri v. Brown, 4 Vet. App. 467 (1993). Greater weight may be placed on one medical professional's opinion over another, depending on factors such as reasoning employed by the medical professionals and whether or not, and the extent to which, they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). Adequate reasons and bases, in short, must be presented if the Board adopts one medical opinion over another. In assessing evidence such as medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. 444, 448-49 (2000). In some cases, the physician's special qualifications or expertise in the relevant medical specialty or lack thereof may be a factor. In every case, the Board must support its conclusion with an adequate statement of its reasoning of why it found one medical opinion more persuasive than the other. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. Nieves-Rodriguez, 22 Vet. App. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). There are substantial and significant factors which favor the valuation of the VA medical opinion over the opinions of Dr. W.B.A. and Dr. K.D.S. in this case. With regards to the first inquiry, it is clear that the March 2011 VA examiner was fully informed of the pertinent factual premises (medical history) of the case. He examined the claims file in conjunction with the examination and he provided an accurate summary of both the service treatment records and the post service treatment records. It is unclear whether or not Dr. W.B.A. and Dr. K.D.S. were fully informed of the medical history in this case. Neither of them provided any details of the Veteran's medical history beyond the single elevated blood pressure reading. Neither of them noted the other in-service blood pressure readings that were within normal limits. Neither of them commented on the fact that the separation examination yielded normal findings. They failed to note the length of time between service and the Veteran's first post service treatment for hypertension. Consequently, the extent of their knowledge of the medical history is unknown. With regards to the second inquiry, the Board notes that all three examiners provided opinions that were unequivocal. However, the Board finds that the opinion of the March 2011 VA examiner far more "fully articulated" insofar as the opinions of Dr. W.B.A. and Dr. K.D.S. consisted of scant to no rationales. In contrast, the VA examiner logically set forth the reasons for the stated conclusion. With regards to the third inquiry (regarding whether the opinion is supported by a reasoned analysis), the Board once again notes that the March 2011 VA examiner's opinion is accompanied by a more detailed rationale that gives the Board an opportunity to see how the examiner evaluated the facts against their medical background and arrived at their conclusion. As noted earlier, Dr. W.B.A. and Dr. K.D.S. had opinions that were based on single elevated blood pressure reading. They failed to reconcile their opinions with all of the other blood pressure readings that were within normal limits. For all of the foregoing reasons, the Board finds the March 2011 VA examiner's opinion to be of greater probative value that the opinions of Dr. W.B.A. and Dr. K.D.S. To the extent that the Veteran believes that his hypertension is related to service, the Board notes that the Veteran is considered competent to report the observable manifestations of his claimed disability. See Charles v. Principi, 16 Vet. App. 370, 374 (2002) ("ringing in the ears is capable of lay observation"); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (lay testimony iterating knowledge and personal observations of witness are competent to prove that claimant exhibited certain symptoms at particular time following service). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), as to the specific issue in this case, the diagnosis and etiology of hypertension fall outside the realm of common knowledge of a lay person as it involves knowledge of the body's vascular (and cardiologic) system. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (stating that lay persons not competent to diagnose cancer). In the absence of a disability in service or for 20 years after service; and with the preponderance of the evidence weighing against a causal connection between the Veteran's current disability and service, the Board finds that a preponderance of the evidence weighs against the claim. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim for entitlement to service connection for hypertension is denied. See Gilbert v. Derwinski, 1 Vet. App 49, 57 (1990). Diabetes The Veteran's primary contention is that his diabetes mellitus is subject to presumptive service connection due to exposure to herbicides. The Veteran's service treatment records fail to reflect any findings attributed to diabetes mellitus; nor are there any findings attributed to diabetes mellitus within one year of discharge from service. A May 2007 VA outpatient treatment report states that "diabetes was diagnosed in about 1990." (VBMS, 7/12/07, p. 3). The Board notes that this would be more than 10 years after the Veteran was discharged from service. The Veteran submitted private treatment report dated May 1990. It reflects that the Veteran's blood pressure was 142/89 (VBMS, 6/12/07). At the bottom of this typed record, there is a handwritten note stating that this is a "record of high blood pressure before his diagnosis of diabetes in 1991." This handwritten message appears to acknowledge that the Veteran was not diagnosed with diabetes mellitus during service or within one year of service. In August 2003, the Naval Department found that there was no evidence in the Veteran's file to substantiate his claim of having any service in Vietnam; and that there were no records of exposure to herbicides (VBMS, 4/15/13). In May 2011, the Veteran reported that he landed in Vietnam on March 13, 1974 and July 15, 1974 (VBMS, 5/9/11). The deck logs of the U.S.S Mauna Kea reflect that on March 13, 1974, the ship arrived at Yokosuka, Japan (having sailed from Guam) (VBMS, 1/17/13, pgs. 21-23). The deck logs reflect that on July 15, 1974, the U.S.S. Mauna Kea was en route from Subic Bay to Pearl Harbor (VBMS, 1/17/13, p. 86). The command history of the U.S.S. Mauna Kea reflects that while the ship rearmed the fleet engaged in combat operations of the coast of North and South Vietnam in January 1973 (before the Veteran was on board the ship); the ship was never in or around Vietnam at any time in 1974 (VBMS, 3/10/11, pgs. 5-6, 9-12). In July 2013, the United States Army and Joint Service Records Research Center (JSRRC) noted that according to the command history provided by the U.S.S. Mauna Kea, the ship was not recorded as having been in Vietnamese waters in 1974. In July 2013, the National Archives and Records Administration (NARA) responded that the deck logs of the U.S.S Mauna Kea do not substantiate any claim of equipment being offloaded to the shores of Vietnam during either March 1974 or July 1974. Moreover, it noted that according to information provided by the JSRRC, the use of Agent Orange in the Republic of Vietnam was suspended in April 1970. In light of the deck logs from the USS Mauna Kea and the responses from the JSRRC and NARA, the Board finds that the preponderance of the evidence weighs against a finding that the Veteran was in Vietnam or was otherwise exposed to herbicides. Consequently, the Board finds that entitlement to service connection for diabetes mellitus on a presumptive basis is not warranted. Nevertheless, in Combee v. Brown, the United States Court of Appeals for the Federal Circuit held that when a Veteran is found not to be entitled to a regulatory presumption of service connection for a given disability, the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. See Combee v. Brown, 24 F.3d 1039, 1043-44 (Fed. Cir. 1994). As such, the Board must not only determine whether the Veteran has a disability which is recognized by VA as being etiologically related to prior exposure to herbicide agents that were used in Vietnam, see 38 C.F.R. § 3.309(e), but also must determine whether his current disability is the result of active service under 38 U.S.C.A. § 1110 (West 2014) and 38 C.F.R. § 3.303(d) (2016). In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). In this case, the Veteran has satisfied the first criteria in that post-service treatment records do reflect a diagnosis of diabetes mellitus. However, neither the second or third elements of service connection have been satisfied. As noted above, neither the service treatment records nor any post-service treatment records within one year of discharge reflect findings attributed to diabetes. In this regard, the earliest possible onset of diabetes is in 1991, which is over a decade after the Veteran was discharged from active service. Additionally, there is no nexus opinion indicating a relationship between his current diabetes mellitus and any incident/disease during service. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim for entitlement to service connection for diabetes mellitus type 2 must be denied. See Gilbert, 1 Vet. App at 57. Right foot The Veteran has alleged that he suffered a knife stab wound to his right foot (specifically, in his right great toe). The RO, in its February 2004 rating decision, appears to have acknowledged that the Veteran sustained a right foot injury in service by noting a record of treatment. However, the RO found the residuals of the injury were acute and transitory; and that the Veteran did not sustain a chronic disability. The Board notes that the service treatment records reflect that in June 1973, the Veteran sustained an "apparent stab wound to the base of the left great toe." The stab wound measured 1/2 inch and caused no apparent tendon damage. The wound was cleaned up and sutures were applied (VBMS, 4/3/12, p. 12). At the Veteran's January 2007 Board hearing, he testified that he sustained a stab wound to his right foot as a result of an assault. He stated that his foot has been giving him problems ever since. He stated that he has been to a podiatrist who has made "special things" for his boots to help hold the toe in place because "the range of motion isn't there and it aggravates where it swells so badly that I can't hardly walk at the end of the day." He also stated that it has a big knot in it where the knife went in; and that there are residual scars. He reported that the knife went clear into the bone. He also reported that his podiatrist stated that the problems that he was having with his foot were a direct result of the knife wound. The Veteran first sought treatment in June 2003. He has consistently stated that he sustained a knife injury to the right great toe in the 1970s (VBMS, 5/26/06, p.3). The impression was "Painful hailux limitus; capsulitis, 1st MPJ." During a November 2005 VA examination for the right knee, the Veteran reported that his right foot has some pain that started in military. A January 2007 treatment report reflects that the Veteran responded well to injection therapy and orthotics/carbon foot plate (VBMS, 2/20/07). The impression was also "Painful hallux limitus" and "1st MPJ capsulitis." The Veteran underwent a VA examination in May 2007. The examiner noted that the claims file had not been sent to him; but that he was able to get a copy of his previous report and he reviewed it. He noted that the Veteran's right foot was stabbed with a knife. The knife stuck in the first metatarsal and was immediately removed. Some sutures were utilized; and the Veteran returned to full duties by three weeks after the injury. The Veteran reported that he has continued to have pain in the right foot since service. He denied any injuries to the right foot since military. He reported that walking is limited to ten minutes due to increasing pain at the right knee and right foot. He also reported some pain at the scar over the first metatarsal and a slight numbness at that scar. Otherwise the right foot felt normal. Upon examination, motion of foot and ankle was normal and equal with dorsiflexion to 10 degrees, plantar flexion to 40 degrees, inversion to 25 degrees, and eversion to 20 degrees. There was some mild pain at the right foot with these movements. Right forefoot had moderate tenderness at a scar. Otherwise forefoot areas are normal. The scar was over the distal part of the first metatarsal (the big toe). The scar was 1/8" x 1/4". It had moderate tenderness and mild numbness. Sensation of the foot was otherwise normal. The examiner was of the opinion that "the right foot symptoms are related to military. In my opinion, it is more likely than not that the present right foot symptoms are related to a knife injury in military." The Board finds that the Veteran has a current right foot disability in the form of a moderately painful and mildly numb scar. This satisfies the first element of service connection. With regards to the second element, the Board notes that the service treatment records reflect a stab injury to the left great toe. The Board questions whether this record accurately described the correct foot/toe. In this regard, the February 2004 rating decision stated there was a right foot injury and the Veteran, in his statements and treatment, has also consistently described a right foot injury. The Veteran is considered competent to report the observable manifestations of his regard an injury and pain to his right foot. As such, the Veteran is competent to report a stab injury to the right great toe (even if the service treatment records state otherwise). The Board finds no contradictions or other reasons to doubt his credibility on this matter. The Board also notes that the scar on his right great toe is consistent with the stab injury allegedly having been sustained in the left great toe. The Board will resolve any doubt in the Veteran's favor on this material issue and find any in-service event/injury to the right foot. Consequently, the second element of a service connection claim has been met. With regards to the third element of a service connection claim, the Board notes that the lone medical opinion from May 2007 addressing a possible causal connection weighs in favor of the claim. The Board notes that the VA physician was aware of the pertinent facts and provided a conclusive opinion that is consistent with the relevant evidence of record. As such, the Board places a great deal of weight on it. Consequently, the Veteran has established all three elements needed to substantiate a service connection claim. In sum, the Board finds that service connection for residuals of a right foot injury, to include scarring, is warranted. Gastroparesis At the outset, the Board notes that the record reflects that service connection is in effect for gastroesophageal reflux disease with hiatal hernia and past history of duodenal ulcers. The record does not reflect that service connection has been established for diabetes mellitus. The Veteran underwent a VA examination in October 2008. The examiner diagnosed the Veteran with GERD with a past history of duodenal ulcers; a hiatal hernia; and diabetic gastroparesis. He noted that the Veteran has had a problem with gastroesophageal reflux disease from the time of his military service and has periodically had duodenal ulcers secondary to this. In addition, the examiner noted that the hiatal hernia is a usual accompaniment of that disorder, especially with time and age. Finally, he opined that "the gastroparesis, however, is an unrelated problem caused by his diabetes. It is more likely than not, however, that his gastroesophageal reflux disease aggravates the gastroparesis." The Veteran submitted a July 2013 statement from registered nurse T.D. She stated that she is the Veteran's primary nurse at dialysis. She stated that the Veteran has chronic gastroparesis and has been frequently symptomatic even in spite of taking medications and following his diet as prescribed. She stated that she has witnessed the Veteran having bouts of emesis on dialysis which are spontaneous and sometimes only partially relived with medications. She stated that many times he has missed family weekend outings because of the discomfort, nausea, and vomiting that is caused by this condition. She was of the opinion that this condition limits the Veteran's activities and therefore his quality of life. Dr. R.G. of Renal Care Consultants stated that he treats the Veteran on dialysis rounds; and that he concurred with T.D.'s statements (VBMS, 7/30/13). This statement did not provide an etiological opinion. The Veteran underwent a VA examination in July 2014. The examiner reviewed the claims file in conjunction with the examination. The examiner noted that the esophageal conditions were stable since the most recent examination. He noted that the Veteran also had "a long-standing and chronic problem of gastroparesis of the stomach, leading to chronic vomiting, unrelated to the esophagus." The Veteran also underwent a VA examination in February 2015. The examiner reviewed the claims file in conjunction with the examination. In the medical history section, the examination report reflects that the Veteran has been diagnosed with chronic diabetic gastroparesis, apparently diagnosed in 2007. The report also reflects that Dr. G., his nephrologist has written a note, dated 7/17/13, stating the chronic nausea and vomiting are "likely to be related to his dialysis & kidney failure." This examiner did not provide a medical opinion. In October 2015, the AOJ obtained a VA opinion. The examiner reviewed the claims file and noted that an August 2015 White City VA primary care note states that Veteran has both gastroparesis and esophageal sphincter dysfunction (an alternate terminology for GERD). The treatment note also stated that the Veteran has had emesis since service but it "has gotten worse'" and is now more frequent and unpredictable so that he "requires immunosuppressives for his kidney transplant and worries he throws his medication up." The October 2015 VA examiner stated that he could find nothing in the claims file to indicate that sufficient testing had been done to establish a separate diagnosis of gastroparesis. She found that "available records do not include any confirmatory study for gastroparesis or even for any additional ongoing 'gerd' related conditions." The October 2015 VA clinician then noted that the most common cause of gastroparesis would be diabetes. The clinician also stated that "though it is true that some patients with severe reflux ALSO vomit as part of their GERD in this veteran's case, the GERD has been documented as 'controlled' in PVAMC notes making veteran's ongoing vomiting less likely to be 'part and parcel' of his GERD." The VA clinician went on to find that if gastroparesis were confirmed, it would not be related to service on a direct basis because the Veteran's in-service vomiting was attributed to a different disability (peptic ulcer disease). Treatment records from Asante Rogue Regional Medical Center, dated February 2016, confirm that although the Veteran has been told that he has gastroparesis based on his clinical symptoms, he has never had a confirmatory imaging study to his knowledge (VBMS, 3/31/16, p. 5). The Board notes that every examiner was in agreement that even assuming that the Veteran has correctly been diagnosed with gastroparesis (in the absence of a nuclear emptying study), that it is a separate condition caused by nonservice-connected diabetes. The Board notes that the October 2008 VA examiner opined that the gastroparesis was due to diabetes mellitus; but that it more likely than not was aggravated by GERD. The July 2014 VA examiner opined that the Veteran's chronic vomiting was "unrelated to the esophagus." The February 2015 VA examiner likewise found that the Veteran's "nausea and vomiting are felt to be related to his kidney failure and dialysis." Finally, the October 2015 VA examiner noted that the Veteran's in-service vomiting was attributed to a different disability (peptic ulcer disease). The Board notes that there are conflicting opinions regarding whether the Veteran's gastroparesis is aggravated by GERD. As previously noted, the Court has held that the Board must determine how much weight is to be attached to each medical opinion of record. It is the Board's duty as a finder of fact to assess and weigh the relevant evidence. As previously noted, in determining the probative value to be assigned to a medical opinion, the Board must consider three factors. The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Nieves-Rodriguez, 22 Vet. App. at 303-04. In this case, the Board finds that all three examiners were fully aware of the Veteran's medical history and gave fully articulated and unequivocal opinions. However, the Board notes the October 2015 VA examiner provided the most thorough analysis. She noted that no definitive testing had been done to confirm a separate diagnosis of gastroparesis. She noted, as did all the examiners, that the most common cause of gastroparesis is diabetes; and that gastroparesis "is even more common in diabetics who have peripheral neuropathy and who must use narcotics for chronic pain (both pertinent to this Veteran)." Finally, she noted that "though it is true that some patients with severe reflux also vomit as part of their GERD, in this Veteran's case, the GERD has been documented as 'controlled' in PVAMC notes making Veteran's ongoing vomiting less likely to be 'part and parcel' of his GERD." The October 2008 VA examiner did not provide any rationale for his opinion regarding aggravation. In light of this, the Board discounts this opinion. Given the thoroughness of the rationale provided by the October 2015 VA examiner; and given that her conclusion is in line with that of the July 2014 VA examiner and the February 2015 VA examiner, the Board finds that these opinions are more probative than that of the October 2008 VA examiner, whose conclusion was given without any reasoned analysis. In sum, the Board finds that the preponderance of the evidence is against a finding of a relationship, to include via aggravation, of the Veteran's current gastroparesis and his active service or his service-connected GERD. As such, service connection for gastroparesis is not warranted. Rating Reductions The RO granted service connection for GERD by way of an October 2008 rating decision. It assigned a 30 percent effective January 22, 2007. In June 2013, the RO proposed reducing the rating from 30 to 10 percent. It effectuated a reduction to 10 percent, effective December 1, 2014, via a September 2014 rating decision. There is no question that a disability rating may be reduced; however, the circumstances under which rating reductions can occur are specifically limited and carefully circumscribed by VA regulations. Dofflemyer v. Derwinski, 2 Vet. App. 277, 280 (1992). In any rating reduction case, particularly those, such as this one, where the rating has been in effect for more than five years, it must be ascertained, based upon a review of the entire recorded history of the condition, whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based upon thorough examinations. 38 C.F.R. § 3.344(a). Ratings on account of diseases subject to temporary or episodic improvement, e.g., manic depressive or other psychotic reaction, epilepsy, psychoneurotic reaction, arteriosclerotic heart disease, bronchial asthma, gastric or duodenal ulcer, many skin diseases, etc., will not be reduced on any one examination, except in those instances where all the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated. Moreover, not only must it be determined that an improvement in a disability has actually occurred, but also that any improvement in a disability reflects an improvement in a Veteran's ability to function under the ordinary conditions of life and work. Id.; Brown v. Brown, 5 Vet. App. 413, 420-22 (1993). The Veteran's service-connected GERD has been rated by the RO under the provisions of Diagnostic Code 7346. Under this regulatory provision, a rating of 60 percent rating is assigned with symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. A 30 percent rating is assigned for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent evaluation where there are two or more of the symptoms of a 30 percent evaluation with less severity. The Veteran's initial 30 percent rating was based on an October 2008 VA examination. The examiner noted that in December 2001, the Veteran was hospitalized at Merle West Medical Center in Klamath Falls with the diagnosis of upper gastrointestinal (GI) bleeding and hematemesis. Esophagogastroduodenoscopy (EGD) showed the pylorus to be somewhat stenotic. Multiple small plaques were visualized in the distal esophagus. Esophageal biopsy showed mild reflux esophagitis; and a biopsy at the gastroesophageal junction showed mild chronic inflammation of the mucosa. The Veteran sought treatment at White City VA Medical Center in September 2002. It was mentioned at that time that he had an EGD and that he was told that he had gastritis and a hiatal hernia. A diagnosis of Barrett's esophagus was entered into the problem list at the VA; but the October 2008 VA examiner noted that the diagnosis was never confirmed. The VA requested a community evaluation from gastroenterologist Dr. J.W. who performed an endoscopy in October 2003 which was normal. The Veteran continued to have indigestion and acid reflux when he lay down. In July 2007, he started having significant periods of vomiting and was diagnosed with diabetic gastroparesis which was somewhat controlled; but he continued to vomit periodically. The Veteran also claimed that he had dysphagia with food sticking in the mid esophagus, as well as at the EG junction. He had to be careful to eat small bites and drink fluids. The June 2013 proposal to reduce the Veteran's rating was based on a March 2012 VA examination (VBMS, 3/6/12, p. 9). In that examination, the examiner found that the Veteran's GERD was manifested by dysphagia, pyrosis (heartburn), reflux, regurgitation, vomiting, and sleep disturbance caused by esophageal reflux. The examiner did not list substernal arm or shoulder pain as a symptom (and the Board notes that this symptom is required in order to warrant a 30 percent schedular rating under DC 7346). Likewise, in a July 2014 VA examination, the examiner listed the Veteran's symptoms as dysphagia, pyrosis, reflux, sleep disturbance caused by esophageal reflux, nausea, and vomiting. There was no mention of substernal arm or shoulder pain. The examiner found that the Veteran's symptoms were stable since the previous examination. The Veteran underwent another VA examination in February 2015. The examiner reviewed the claims file in conjunction with the examination. This time, the examiner listed the Veteran's GERD symptoms as dysphagia, pyrosis, reflux, regurgitation, nausea, vomiting, sleep disturbance caused by esophageal reflux, and substernal pain. At the Veteran's October 2016 Board hearing, he testified that he experiences reflux a couple times per day on almost every single day. He also testified that he has pain in the substernal area pretty much every day. He also reported that occasionally he wakes up in the middle of the night with bile in his mouth. He then stated that this happens "pretty much every night." He also testified that some of those times it is a "full on regurgitation and it kind of chokes you and then of course you're up for three to four hours after that." He testified that the week of the hearing, this had happened on four nights. He stated that he has experienced both weight losses and weight gains due to GERD. He also said that he has some substernal pain in his shoulder and arm. The RO reduced the Veteran's rating because it noted that the March 2012 VA examination showed significant improvement of the Veteran's GERD. From a comparison of the 2008 and 2012 VA examination reports, it appears that the only symptom that was present in October 2008 that was not present in March 2012 was substernal shoulder or arm pain. It therefore appears that the absence of this one symptom was the basis for the reduced rating. However, the Board notes that substernal pain was noted at the subsequent February 2015 VA examination. Moreover, at the Veteran's October 2016 Board hearing, the Veteran competently and credibly testified that he still experiences substernal pain. In light of these facts, the Board cannot find that all the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated. 38 C.F.R. § 3.344(a). Similarly, as a the 2015 VA examination report and 2016 testimony show the return of substernal arm pain the Board finds that the evidence does not make it reasonably certain that the improvement noted in March 2012 is or was maintained under the ordinary conditions of life. Consequently, the Board finds that based upon a review of the entire recorded history of the Veteran's GERD, that there was sustained improvement under ordinary conditions of the Veteran's life. As such, the Board finds the propriety of the reduction from 30 to 10 percent was not in full accordance with § 3.344(a). As a result of this finding, a restoration of the 30 percent rating for GERD is warranted. See 38 C.F.R. § 3.344(b) (stating that the prior rating will be continued "if doubt remains"). ORDER Entitlement to service connection for hypertension is denied. Entitlement to service connection for diabetes mellitus, to include as due to exposure to herbicides, is denied. Entitlement to service connection for residuals of a right foot injury, to include scarring, is granted. Entitlement to service connection for gastroparesis as secondary to GERD is denied. Entitlement to restoration of a 30 percent rating for GERD is granted. REMAND Kidney In November 2016, the Veteran submitted articles from the internet (VBMS, 11/2/16). These articles cite a VA St. Louis Health Care System study that found that medication taken for heartburn (GERD) can result in an increased risk of developing chronic kidney disease. As discussed above, the record reflects that service connection is in effect for GERD. The Board finds that this article indicates a possible relationship between kidney disease and his medication for GERD. In this regard, entitlement to service connection for kidney disease as secondary to GERD has not been considered by the RO. The Board finds that a VA examination is necessary to determine whether the Veteran's kidney disability was caused or aggravated by GERD, to include medications taken to treat GERD. Accordingly, the case is REMANDED for the following actions: 1. Schedule the Veteran a VA examination for the purpose of determining the nature and etiology of the Veteran's kidney disability. The claims file is to be reviewed by the examiner to become familiar with the Veteran's pertinent medical history. Following a review of the relevant evidence, to include the claims file, service treatment records, post-service treatment records; a history obtained from the Veteran, the clinical evaluation, and any tests that are deemed necessary, the examiner should opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's kidney disability began during or is causally related to service, to include whether any disability was caused, or aggravated by, his service connected GERD or medications taken to treat GERD. The examiner should acknowledge the articles submitted by the Veteran and if the examiner's conclusion differs from those articles, he/she should reconcile the contrary findings. The examiner is advised that the Veteran is competent to report injuries and symptoms and that his reports must be considered in formulating the requested opinion. The examiner is to provide a comprehensive rationale for all opinions and conclusions. 2. After completion of the above, the AMC should review the expanded record and determine if the benefits sought can be granted. If the claim remains denied, then the AMC should furnish the Veteran and his representative with a supplemental statement of the case, and afford a reasonable opportunity for response before returning the record to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ Paul Sorisio Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs