Citation Nr: 1758094 Decision Date: 12/14/17 Archive Date: 12/28/17 DOCKET NO. 13-19 607 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to a service-connected disability or medications prescribed for a service-connected disability. 2. Entitlement to service connection for hypertension, to include as secondary to a service-connected disability or medications prescribed for a service-connected disability. REPRESENTATION Veteran represented by: Oregon Department of Veterans' Affairs WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD T. Berryman, Associate Counsel INTRODUCTION The Veteran had active service in the Navy from July 1963 to December 1967. This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. In connection with this appeal, the Veteran testified at a hearing before the undersigned Veterans Law Judge in April 2016. A transcript of that hearing is of record. In September 2016, the Board remanded the Veteran's claims for further development. The Board is satisfied that there was at the very least substantial compliance with its remand directives. See Dyment v. West, 13 Vet. App. 141, 146-157 (1999). In November 2016, the RO granted service connection for erectile dysfunction. This represents a complete grant of his appeal in regard to this claim. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). This issue is no longer before the Board. FINDINGS OF FACT 1. GERD was not shown in service; and the weight of the evidence fails to establish that the Veteran's diagnosed GERD is etiologically related to his active service or was caused or aggravated by a service-connected disability or medications prescribed to treat a service-connected disability. 2. Hypertension was not shown in service or within a year of service discharge; and the weight of the evidence fails to establish that the Veteran's diagnosed hypertension is etiologically related to his active service or was caused or aggravated by a service-connected disability or by medications prescribed to treat a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for GERD have not been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.310 (2017). 2. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). In this case, required notice was met, and neither the Veteran, nor his representative, has either alleged, or demonstrated, any prejudice with regard to the content or timing of VA's notices or other development. See Shinseki v. Sanders, 129 U.S. 1696 (2009). Thus, adjudication of the claims at this time is warranted. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service treatment records (STRs), VA treatment records, and private treatment records have been obtained. VA attempted to obtain Social Security Administration (SSA) records; however, SSA notified VA that it was unable to locate the Veteran's records. Additionally, the Veteran testified at a hearing before the Board in April 2016 The Veteran was also provided VA examinations with addendum opinions and neither the Veteran, nor his representative, has objected to the adequacy of the examinations conducted during this appeal. See Sickels v. Shinseki, 643 F.3d, 1362, 1365-66 (Fed. Cir. 2011). As described, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established under 38 C.F.R. § 3.303(b), where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. The continuity of symptomatology provision of 38 C.F.R. § 3.303(b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established with certain chronic diseases based upon a legal presumption by showing that the disorder manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. Such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disability which is aggravated by a service connected disability. In order to prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability; (2) evidence of a service connected disability; and (3) medical nexus evidence establishing a connection between the service connected disability and the current disability. Wallin v. West, 11 Vet. App. 509 (1998). The Veteran filed a service connection claim for GERD in June 2009 and for hypertension in February 2010, which were denied by February 2010 and November 2010 rating decisions, respectively. The Veteran asserts that his GERD is due to his active service and/or caused by his service-connected posttraumatic stress disorder (PTSD). He asserts that his hypertension is secondary to his service-connected PTSD. For VA compensation purposes, the term "hypertension" means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. Multiple blood pressure readings are required to confirm the diagnosis of hypertension with two or more readings on at least three different days. 38 C.F.R. § 4.104, DC 7101, Note 1. The Veterans STRs show he had normal blood pressure readings at his July 1963 entrance examination and his December 1967 separation examination. He also had normal examinations of his throat, abdomen, and heart. On medical history surveys completed in conjunction with his physicals, the Veteran denied having frequent indigestion, stomach trouble, or high blood pressure. After his separation from active service, the Veteran's reserve STRs show that in July 1970 and July 1971 he continue to have normal blood pressure readings with normal examinations of the throat, abdomen, and heart. He also continued to deny having frequent indigestion, stomach trouble, and high blood pressure. Regarding GERD, the first medical evidence of GERD does not appear until 2002, almost four decades after his separation from active service, when an endoscope showed the presence of chronic GERD. Regarding hypertension, the first medical evidence of hypertension having been diagnosed does not appear until approximately 1992, which is more than two decades after his separation from service. As such, the record contains no diagnosis of hypertension either in service or within one year after service, which would preclude service connection on the basis of continuity of symptomology or on any presumptive basis. The Veteran has not argued to the contrary and instead argues his hypertension is the result of his service-connected PTSD. There is also no medical evidence linking the Veteran's current hypertension to his active service, and he has not submitted any medical opinion that even suggests a relationship between his hypertension and his military service. See Shedden, 381 F.3d 1163, 1167. In October 2009, the Veteran was afforded a VA examination for his GERD. He reported an onset of abdominal pain, constipation, and loose stools dating back to 1975. In October 2009, the Veteran was afforded a VA examination for his PTSD. After interviewing the Veteran, reviewing his claims file, and conducting an examination, the examiner reported that there was evidence in medical literature of a connection between PTSD and GERD, but it would be mere conjecture to opine on a level of connection due to the extensive rebuilding of the Veteran's esophagus post-cancer treatment. In April 2016, the Veteran submitted a medical article that discussed a possible relationship between PTSD and hypertension. At the April 2016 Board hearing, the Veteran testified that he had experienced symptoms of GERD in service but had generally not gone to sick bay unless in dire need. He also testified that he did not mention his GERD at separation. He testified that he started treatment in 1969. His wife testified that he had symptoms of GERD after his separation from service. In October 2016, the Veteran was afforded a VA examination for his GERD and hypertension. The Veteran reported that he began treatment for hypertension approximately 10 to 20 years previously. After interviewing the Veteran, reviewing his claims file, and conducting a physical examination, the VA examiner opined that the Veteran's GERD and hypertension were less likely than not proximately due to his service-connected PTSD. The examiner reported that his GERD was more likely related to the physiology and anatomy of his upper gastrointestinal system. The examiner reported that an anatomical or physiological link with his PTSD was not identified. The examiner reported that the Veteran's hypertension was more likely related to his innate physiology, age, lifestyle factors, and genetics. The examiner reported that there was no identifiable relationship between hypertension and PTSD. In a December 2016 addendum opinion, the October 2016 examiner opined that the Veteran's GERD was less likely than not due to his active service. The examiner noted that the Veteran denied having any stomach trouble in 1967 and 1971. The examiner opined that the Veteran's GERD was less likely than not due to medications prescribed for his service-connected PTSD. In a January 2017 addendum opinion, the October 2016 VA examiner opined that the Veteran's hypertension was less likely than not due to medications prescribed for a service-connected disability. In a February 2017 addendum opinion, the October 2016 VA examiner opined that the Veteran's hypertension was less likely than not due aggravated by a service-connected disability or medications prescribed for a service-connected disability. The examiner reviewed the medical articles submitted by the Veteran and concluded there was insufficient medical data to conclude that the Veteran's PTSD and its treatment sufficiently aggravated his hypertension. In an April 2017 addendum opinion, the October 2016 VA examiner opined that the Veteran's hypertension was less likely than not due to the Veteran's active service. The examiner reported that there was insufficient evidence to identify his hypertension as beginning during his active service as his STRs showed normal blood pressure readings. In a May 2017 addendum opinion, the October 2016 VA examiner opined that the Veteran's GERD and hypertension were not caused by or aggravated beyond their natural progression by the Veteran's service-connected disabilities. The examiner reported that a causal link was not identified between the Veteran's GERD or hypertension and his service-connected disabilities. In a July 2017 addendum opinion, the October 2016 VA examiner reaffirmed the May 2017 addendum opinion. The examiner reported that neither the Veteran's primary medical care providers nor his psychiatric medical providers have identified a significant causal link between his current medications and his GERD or hypertension and that the probability of his current medications causing or aggravating his GERD or hypertension was less likely than not. Regarding the medical article submitted by the Veteran regarding PTSD and hypertension, the United States Court of Appeals for Veterans Claims (the Court) has held that a medical article or treatise "can provide important support when combined with an opinion of a medical professional" if 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. Mattern v. West, 12 Vet. App. 222, 228 (1999). However, the medical article submitted by the Veteran is not accompanied by the opinion of any medical expert. Nevertheless, given the articles, the Board sought a number of medical opinions to review the studies and treatises, but ultimately, the medical professionals who reviewed the evidence found that it did not link the Veteran's claimed disabilities of hypertension and GERD to either a service connected disability or to medication prescribed to treat a service connected disability. After weighing all the evidence, the Board finds great probative value in the October 2016 VA examiner's opinions. These negative opinions are sufficient to satisfy the statutory requirements of producing an adequate statement of reasons and bases where the expert has fairly considered material evidence which appears to support the Veteran's position. Wray v. Brown, 7 Vet. App. 488, at 492-93 (1995). Consideration has been given to the Veteran's personal assertion that his GERD was due to his active service and that his GERD and hypertension were caused by a service-connected disability or medications prescribed for a service-connected disability. 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 issues in this case, the etiology of GERD and hypertension, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). GERD and hypertension are not the type of conditions that are readily amenable to mere lay diagnosis or probative comment regarding their etiology, as the evidence shows that physical examinations that include esophagogastroduodenoscopy, multiple blood pressure readings, and kidney function studies are needed to properly assess and diagnose the disorders. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); and Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). That is, although the Board readily acknowledges that Veteran is competent to report perceived symptoms of both GERD and hypertension, he has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that he has received any special training or acquired any medical expertise in evaluating gastrointestinal disorders such as GERD, cardiovascular disorders such as hypertension, or psychiatric disorders such as PTSD. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Accordingly, the Veteran's assertions do not constitute competent medical evidence. As such, the criteria for service connection for GERD and hypertension have not been met, and the Veteran's claims are denied. ORDER Service connection for GERD is denied. Service connection for hypertension is denied. ____________________________________________ MATTHEW W. BLACKWELDER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs