Citation Nr: 1758086 Decision Date: 12/14/17 Archive Date: 12/28/17 DOCKET NO. 11-26 360 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to service connection for gastrointestinal reflux disorder (GERD). 2. Entitlement to service connection for monoclonal gammopathy. 3. Entitlement to service connection for Raynaud's disease. 4. Entitlement to service connection for atrial fibrillation. ATTORNEY FOR THE BOARD J. Wozniak, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1970 to July 1975 and from July 1977 to September 1998. This matter is before the Board of Veterans' Appeals (Board) on appeal from a February 2010 rating decision of the Baltimore, Maryland, Department of Veterans Affairs (VA) Regional Office (RO). In April 2017, the Board remanded the appeal to the RO for additional development. Pursuant to VA's duties to notify and assist the Veteran, VA advised the claimant how to substantiate an application for benefits, obtained all relevant and available evidence and conducted any appropriate medical inquiry. The appeal is ready for appellate review. FINDINGS OF FACT 1. The Veteran's GERD originated during active service. 2. The Veteran's monoclonal gammopathy did not originate in service and was not caused or aggravated by his service-connected bilateral lower extremity peripheral neuropathy. 3. The Veteran's Raynaud's disease did not originate in service and was not caused or aggravated by his service-connected bilateral lower extremity peripheral neuropathy. 4. The Veteran's atrial fibrillation did not originate in service and was not caused or aggravated by his service-connected bilateral lower extremity peripheral neuropathy. CONCLUSIONS OF LAW 1. The criteria to establish service connection for GERD have been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2016). 2. The criteria to establish service connection for monoclonal gammopathy, to include as secondary to bilateral lower extremity peripheral neuropathy have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2016). 3. The criteria to establish service connection for Raynaud's disease, to include as secondary to bilateral lower extremity peripheral neuropathy have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2016). 4. The criteria to establish service connection for atrial fibrillation, to include as secondary to bilateral lower extremity peripheral neuropathy have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection may be granted for current disability arising from disease or injury incurred or aggravated by active service. 38 U.S.C.A. § 1110. Service connection may 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). Service connection generally requires (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) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection shall be granted on a secondary basis under the provisions of 38 C.F.R. § 3.310 (a) where it is demonstrated that a service-connected disorder has caused a nonservice-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Service connection is currently in effect for multiple disabilities, including bilateral lower extremity peripheral neuropathy. A. Gastrointestinal Reflux Disorder (GERD) The Veteran's December 2015 examination states that the Veteran has GERD. In the Veteran's July 1998 report of medical history he indicated experiencing frequent indigestion and stomach, liver, or intestinal trouble. In December 2015, the Veteran was afforded a VA examination. The Veteran reported experiencing acid reflux since 1996, with symptoms including increased saliva production, upper chest pain, and awakening due to reflux of liquid. The examiner indicated the Veteran experiences dysphagia, reflux, regurgitation, pain, sleep disturbances, and nausea. The examiner noted no complaints or diagnosis of reflux during active service and opined that the Veteran's GERD was not incurred in service. However, the Veteran's July 1998 report of medical history discusses indigestion and medical records dated December 1995 indicating significant discomfort in his esophagus, aggravated by coffee and strenuous exercise. The December 1995 treatment record also indicates the Veteran relieves his discomfort by eating food and taking antacids. The Board affords the examiner's negative nexus statement low probative value due to inaccurate statements regarding the Veteran's medical record, however, the Board credits the examiner's statements regarding the Veteran's current symptoms. In June 2017, the Veteran was afforded a VA examination. The Veteran reported experiencing symptoms of reflux since 1997 and noted continued use of Ranitidine to control symptoms. The Veteran reported that he was woken up due to excessive salivation and chest pain. The Veteran reported recurrent epigastric distress, dysphagia, pyrosis, reflux, regurgitation, nausea, pain, and sleep disturbance. The examiner stated there was no mention of GERD in the Veteran's medical record and opined that his current condition was not connected to service or the Veteran's service-connected bilateral lower extremity peripheral neuropathy. The Board notes that medical records do exist from December 1995 and July 1998 in which the Veteran reports indigestion, and discomfort in his esophagus. Due to this oversight by the examiner the Board affords this examination low probative value but credits the description of current symptoms. Because it involves subjectively observable symptoms, the Veteran is competent to report that GERD was incurred in service and it has existed from service to the present. See 38 C.F.R. § 3.159(a)(2); Horowitz v. Brown, 5 Vet. App. 217, 222-23 (1993); Connolly v. Derwinski, 1 Vet. App. 566, 568-70 (1991). The Veteran's medical records indicate in-service complaints of reflux and digestive problems and the Veteran's separation examination reports frequent indigestion, stomach, liver, and intestinal trouble. While the VA medical opinions state that the Veteran's GERD likely began after service separation, the Veteran has explained that it began during active service. Given the existence of evidence both for and against the claim, the Board finds that the evidence is in relative equipoise as to whether the Veteran's GERD arose during active service. Upon resolution of all reasonable doubt in the Veteran's favor, the Board concludes that service connection is warranted for GERD and the claim is granted. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. B. Monoclonal gammopathy In December 2009, the Veteran was afforded a VA examination. The examiner noted slightly elevated alpha-2 levels but stated that protein, albumin, and betaglobulins were all within normal ranges. The examiner concluded that there was no evidence of elevated immunoglobulins in the Veteran's file. In December 2015, the Veteran was afforded a VA examination. The examiner noted a minimally elevated alpha-2 globulin level in 1997 but stated that alpha-2 globulin abnormalities are not casually related to monoclonal gammopathies. The examiner concluded that the Veteran's elevated alpha-2 globulin level in service was not a precursor to the IgA lambda monoclonal gammopathy detected in 2007. In June 2017, the Veteran was afforded a VA examination. The Veteran indicated anemia and minimal elevation in the alpha-2 fraction beginning in 1997. The examiner stated that blood tests from February 2017 did not reveal significant diagnostic findings. The examiner also noted no diagnosis or treatment for monoclonal gammopathy in-service and concluded that there is no medical connection between monoclonal gammopathy and bilateral lower extremity peripheral neuropathy. In an October 2017 statement, the Veteran indicated that he experienced anemia while on active duty in 1997 and that the condition was monitored at Walter Reed Army Medical Center after the Veteran's retirement. The Veteran also indicated that he was diagnosed with monoclonal gammopathy in 2007. A preponderance of the evidence is against a finding that the Veteran's monoclonal gammopathy originated during service. There is some medical evidence indicating slightly abnormal alpha-2 blood counts in 1997, however, three separate VA examiners have concluded there was no diagnosis or treatment for monoclonal gammopathy during service. The June 2017 VA examiner also concluded there was no nexus between the Veteran's monoclonal gammopathy and his service-connected bilateral lower extremity peripheral neuropathy. Therefore, service connection is not warranted and the claim is denied. C. Raynaud's disease Raynaud's disease is a "chronic disease" listed under 38 C.F.R. § 3.309(a). Therefore, the provisions of 38 C.F.R. § 3.303(b) are for application. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. 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. With chronic disease as such during active service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected unless they are clearly attributable to intercurrent causes. Generally, if a condition noted during active service is not shown to be chronic, then, a "continuity of symptoms "after service is required to establish service connection. 38 C.F.R. § 3.303(b). As a chronic disease, Raynaud's disease will be considered to have been incurred in or aggravated by service if the disease becomes manifest to a compensable degree within one year from the date of service separation. 38 C.F.R. § 3.307(a)(3). The Veteran was diagnosed with Raynaud's disease in 2010. There is no evidence of symptoms of Raynaud's disease in service and the Veteran's July 1998 examination for service separation states the Veteran has normal upper extremities. In December 2015, the Veteran was afforded a VA examination. The Veteran reported receiving a diagnosis for Reynaud's disease in 2010 and experiencing symptoms since 2007, nine years after service separation. The examiner opined that the Veteran's Reynaud's disease is less likely than not the result of service. In June 2017, the Veteran was afforded a VA examination. The Veteran reported numbness and discoloration of his hands beginning in 2007. The Veteran reported he was diagnosed with Raynaud's disease in 2009. The examiner stated that Raynaud's diseased was not caused by service or the Veteran's service-connected bilateral lower extremity peripheral neuropathy as the two conditions are not medically related. In an October 2017 lay statement the Veteran noted that he submitted medical literature linking Raynaud's disease with monoclonal. The Veteran indicated that his Raynaud's disease was diagnosed in 2010 and his monoclonal gammopathy was detected in 2007. A preponderance of the evidence is against a finding that the Veteran's Raynaud's disease originated during service. The Veteran was first seen for his Raynaud's disease in 2010, many years after service separation, and no competent medical provider has opined that the Veteran's Raynaud's disease began in or as a result of service. Therefore, service connection is not warranted and the claim is denied. D. Atrial fibrillation There is no evidence of symptoms of heart problems in service and the Veteran's July 1998 examination for service separation states the Veteran has a normal heart. In June 2004, the Veteran was given a stress test and the results were reported as "prognostically normal." In December 2015, the Veteran was afforded a VA examination. The examiner documented some medical history regarding a fibrillation in 2000 but reported that multiple EKGs do not reflect evidence of a fibrillation. The examiner also stated that a full cardiac workup completed in 2004 only shows premature ventricular contractions (PVCs). In June 2017, the Veteran was afforded a VA examination. The Veteran reported symptoms starting in 1996 without a diagnosis. The Veteran also noted experiencing an irregular heartbeat and light-headedness, with both resolving after a couple hours. The examiner opined that the Veteran had an acute condition during service with no evidence of chronicity of care. The examiner also reported that the Veteran's atrial fibrillation could not be diagnosed and therefore there is no relationship to the Veteran's service-connected bilateral lower extremity peripheral neuropathy. In an October 2017 lay statement the Veteran indicated that he had cardiac symptoms while in service but did not receive a diagnosis. The Veteran also stated that he experienced a hospitalization in 2000 due to an episode of atrial fibrillation. A preponderance of the evidence is against a finding that the Veteran's atrial fibrillation originated during service. The Board has considered the Veteran's statements that he experienced an atrial fibrillation, however, VA examiners in December 2015 and June 2017 have expressed doubts as to whether the Veteran experienced an atrial fibrillation at all. Furthermore, no competent medical provider has opined that the Veteran's atrial fibrillation began in or as a result of service. Therefore, service connection is not warranted and the claim is denied. ORDER Service connection for GERD is granted. Service connection for monoclonal gammopathy is denied. Service connection for Raynaud's disease is denied. Service connection for atrial fibrillation is denied. ____________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs