Citation Nr: 1753870 Decision Date: 11/24/17 Archive Date: 12/01/17 DOCKET NO. 09-00 270A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to service connection for a parathyroid disorder as secondary to posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Koria B. Stanton, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1966 to August 1968. This matter comes before the Board of Veterans Appeals (Board) on appeal from a May 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. The Board remanded this matter in July 2014 for additional development. At such time, the issue of entitlement to service connection for fibromyalgia was also remanded. In a November 2014 rating decision, the Agency of Original Jurisdiction (AOJ) granted service connection for fibromyalgia. Therefore, as the benefit sought on appeal has been granted in full, this issue is no longer before the Board. In January 2016, the Board denied service connection for a parathyroid disorder, to include as due to herbicide exposure or as secondary to PTSD. In addition to such issue, the Board remanded the issue of entitlement to service connection residuals of traumatic brain injury (TBI) assessed as a cognitive disorder for the issuance of a statement of the case pursuant to Manlincon v. West, 12 Vet. App. 238 (1999). The Veteran appealed the Board's denial of service connection for a parathyroid disorder to the United States Court of Appeals for Veterans Claims (Court). In December 2016, the Court granted a Joint Motion for Partial Remand (Joint Motion) that vacated the Board's January 2016 only as to the issue of entitlement to service connection for a parathyroid disorder as secondary to PTSD and remanded it for further consideration. In this regard, the Joint Motion noted that it did not disturb the Board's denial of entitlement to service connection for a parathyroid disorder due to herbicide exposure or, alternatively, on a direct basis. Consequently, the Board's January 2016 decision on such theories of entitlement is final. Thereafter, in April 2017, the Board remanded the claim for service connection for a parathyroid disorder as secondary to PTSD for additional development and it now returns for further appellate review. With regard to the claim for service connection for a TBI, a statement of the case was issued in May 2016 and the Veteran perfected his appeal of such issue in June 2016. However, the AOJ has not yet certified the issue to the Board. Furthermore, in connection with such appeal, he has requested a Board video-conference hearing before a Veterans Law Judge. Consequently, as the matter is not ripe for Board adjudication, it will be the subject of a separate Board decision issued at a later date. See 38 C.F.R. § 19.35 (2016); Carter v. McDonald, 794 F.3d 1342, 1344 (Fed. Cir. 2015). FINDING OF FACT A parathyroid disorder is not caused or aggravated by the Veteran's service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for a parathyroid disorder as secondary to PTSD have not been met. 38 U.S.C. §§ 1110, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION I. Preliminary Matters The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). While the Veteran's representative generally argued that the VA opinions obtained in this matter are inadequate for adjudication purposes, which will be addressed further herein, neither he nor the Veteran has alleged any other deficiency with respect to VA's duties to notify or assist. See Scott, supra (holding that "the Board's obligation to read filings in a liberal manner does not require the Board...to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). II. Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran is seeking service connection for a parathyroid disorder. Specifically, he asserts that such disorder is caused or aggravated by his service-connected PTSD. In this regard, the Board observes that the Veteran is currently service-connected for PTSD, evaluated as 70 percent disabling. As an initial matter, the Board finds that the evidence of record confirms that the Veteran has a current diagnosis of a parathyroid disorder. Specifically, in conjunction with his October 2013 VA examination, as well as during treatment, the Veteran was noted to have hypothyroidism since 2013 and hyperparathyroidism since 1983. Thus, the remaining question is whether the Veteran's parathyroid disorder is caused or aggravated by his service-connected PTSD. In this regard, the Veteran underwent a VA examination in October 2013 in relation to his claim. However, as the Board explained in its July 2014 remand, the October 2013 VA examiner did not offer any opinion with respect to the relationship between the Veteran's parathyroid disorder and his service-connected PTSD . In light of such deficiency, the Board remanded for an addendum opinion, which was rendered in September 2014. In the September 2014 addendum opinion, the VA examiner opined that it was less likely than not that the Veteran's parathyroid disorder was caused by his service-connected PTSD. In support of such opinion, the examiner reported that the cause for primary hyperparathyroidism, such as irradiation or the rare genetic abnormalities in the MEN syndromes, could be identified in only a small number of patients. She further reported that the following pathologic disorders had been found with hyperparathyroidism: adenoma, parathyroid hormone, glandular hyperplasia, and carcinoma. Here, the examiner indicated that PTSD was not considered to be an etiology of hyperparathyroidism. Additionally, she further opined that it was less likely than not that the Veteran's parathyroid disorder was aggravated by his service-connected PTSD. As rationale for the opinion, the examiner reported that the Veteran's parathyroid disorder was diagnosed in 1983 after testing was performed to evaluate his complaint of chronic fatigue. She further reported that the Veteran's PTSD was diagnosed in July 2004. The examiner further indicated that the Veteran's parathyroid disorder was diagnosed approximately 20 years prior to his PTSD diagnosis. As stated previously, the Board first denied the Veteran's claim in January 2016, primarily on the basis of the September 2014 VA examiner's opinion. However, the Joint Motion found that such opinion did not rule out the possibility that the Veteran's parathyroid disorder was aggravated by his PTSD, but rather focused on causation. Specifically, the parties found that the mere fact that the Veteran's PTSD was diagnosed after his parathyroid disorder did not adequately resolve whether his PTSD was currently aggravating his parathyroid disorder. Hence, the September 2014 VA examiner's opinion with respect to the aggravation prong of secondary service connection has minimal probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); 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"). Consequently, an addendum opinion was obtained in April 2017 by the same VA examiner pursuant to the April 2017 remand. In such addendum opinion, the VA examiner opined that it was less likely than not that the Veteran's parathyroid disorder was aggravated by his service-connected PTSD. As rationale for the opinion, the examiner reported that chronic stress could actually lead to the development of a thyroid disorder; however, the four parathyroid glands, located posterior to the thyroid gland, regulated calcium homeostasis through the release of a parathyroid hormone, and such hormone was not affected by stress. The Board has carefully reconsidered the facts of this case, including the concerns raised in the Joint Motion. Ultimately, the appeal must again be denied because the preponderance of the evidence weighs against the Veteran's claim. In this regard, the Board places great probative weight on the September 2014/April 2017 VA examiner's combined opinions that the Veteran's parathyroid disorder is not caused or aggravated by his service-connected PTSD. Specifically, the April 2017 VA opinion focused on the complex medical questions in the case, including the concerns raised in the Joint Motion. Here, as noted in the Joint Motion and April 2017 remand, the examiner did not rely on the fact that the Veteran's PTSD was diagnosed after his parathyroid disorder in determining that his PTSD was not aggravating his parathyroid disorder . Furthermore, such opinions considered all of the pertinent evidence of record, and provided a detailed rationale for the conclusions reached, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. The Veteran has not submitted medical evidence to refute the September 2014/April 2017 VA opinions or otherwise diminish their probative weight. In this regard, the Board acknowledges the Veteran's representative's argument in his October 2017 Appellant's Post-Remand Brief that the VA opinions obtained in this case are inadequate for adjudication purposes. Specifically, he alleges that "VA failed its duty to assist by failing to provide an adequate medical opinion that could be justifiably relied upon by the rating authority in order to evaluate the [V]eteran's disability." However, he has not offered specific arguments as to the alleged inadequacies in the foregoing VA opinions. In this regard, a VA examiner is presumed to have properly discharged his or her duties as a health professional (presumption of regularity) in a review of the record, in interviewing the Veteran, and supporting his or her opinion with medical analysis applied to the significant facts of the case. See Rizzo v. Shinseki, 580 F.3d 1288, 1292 (Fed Cir. 2009) (applying the presumption of regularity to VA medical examiners in the discharge of their regular duties). The presumption of regularity is rebuttable by clear evidence to the contrary. Miley v. Principi, 366 F.3d 1343, 1347 (Fed. Cir. 2004). As the Veteran's representative has not pointed to any actual error, deficiency, incorrect application of medical principles, or any other specific failing of the VA examiner in this case, the Board finds his arguments as to the alleged inadequacy of the VA opinions to be without merit. The Board notes that the Veteran has contended on his own behalf that his current parathyroid disorder is caused or aggravated by his service-connected PTSD. The Veteran, as a layperson, is certainly competent to report matters within his personal knowledge, such as the occurrence of an injury or event, or his own symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). However, in the instant case, the Board finds that the question regarding the potential relationship between a parathyroid disorder and his service-connected PTSD to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). In this regard, while the Veteran is competent to describe his current manifestations of his parathyroid disorder as well as his history of claimed symptoms and treatment for such disorder, the Board accords such statements regarding the etiology of such disorder little probative value as he is not competent to opine on such complex medical questions. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). There is no indication that the Veteran possesses the requisite medical knowledge regarding the causes of a parathyroid disorder and the impact PTSD may have on such a diagnosis. Moreover, the Veteran has offered only conclusory statements regarding the relationship between his service-connected PTSD, and his current parathyroid disorder. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Therefore, the Board affords the Veteran's statements as to the etiology of his parathyroid disorder no probative weight. Therefore, based on the foregoing, the Board finds that the Veteran's parathyroid disorder is not caused or aggravated by his service-connected PTSD. As such, service connection for such disorder is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim for service connection for a parathyroid disorder, that doctrine is not applicable. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER Service connection for a parathyroid disorder as secondary to PTSD is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs