Citation Nr: 1803189 Decision Date: 01/18/18 Archive Date: 01/29/18 DOCKET NO. 13-01 990 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for epistaxis, claimed as secondary to service-connected status post deep vein thrombosis (DVT) with post phlebitis syndrome. REPRESENTATION Appellant represented by: Virginia Department of Veterans Services ATTORNEY FOR THE BOARD C. Lamb, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1982 to August 2010. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2011 rating decision of the Winston-Salem, North Carolina, Department of Veterans Affairs (VA) Regional Office (RO). The record shows the Veteran was scheduled for a Board Central Office hearing in October 2017. However, the Veteran did not report for his scheduled Board hearing. Because the Veteran has neither submitted good cause for failure to appear nor requested to reschedule the hearing, the request for a hearing is deemed withdrawn. See 38 C.F.R. § 20.704(d) (2017) (failure to appear for a scheduled hearing treated as withdrawal of request). The record also includes a July 2017 email correspondence from the Virginia Department of Veterans Services (VDVS) to Veterans Benefits Administration (VBA) noting that a July 2016 VA Form 21-22 received by VA was not co-signed by VDVS. Accordingly, VDVS stated that it was their understanding they would not be recognized as the Veteran's representative. However, the record also includes a July 2010 VA Form 21-22 which also assigned VDVS as the representative and this form did not require a co-signature by the appointed service organization. Thereafter, VDVS was copied on communications to the Veteran. See March, June, and October 2011 Notification Letters and December 2012 Statement of the Case. The record does not reflect that the Veteran has revoked VDVS's power of attorney to act as his representative at any time. Thus, the Board will continue to recognize VDVS as the Veteran's representative. FINDING OF FACT The Veteran's epistaxis is etiologically related to medication used to treat his service-connected status post DVT with post phlebitis syndrome. (CONTINUED ON NEXT PAGE) CONCLUSION OF LAW The criteria for service connection for epistaxis are met. 38 U.S.C. §§ 1110, 1112, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist VA has specified duties to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits, as well as certain assistance duties. However, given the disposition of the appeal below, discussion of VA's compliance with those duties are not necessary, and any deficiencies in such notice or assistance are harmless. In the decision below, the Board grants the service connection claims for epistaxis. To the extent there are any notice defects as to the initial rating and effective date elements when effectuating the award, the Board trusts the RO will ensure they are rectified. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. § 1110, 1131 (2012); 38 C.F.R. § 3.303 (2017). In order to establish entitlement to service connection, there must be (1) 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. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Lay evidence presented by a Veteran concerning continuity of symptoms after service may not be deemed to lack credibility solely because of a lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (2006). The Board has the authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Epistaxis The Veteran asserts that he has recurrent epistaxis (nose bleeds) that is secondary to his service-connected status post DVT with post phlebitis syndrome. Specifically, the Veteran asserts that his epistaxis was caused by medication used to treat the above mentioned service-connected condition. After a review of the evidence of record, the Board finds that service connection for epistaxis is warranted. The Veteran's service treatment records (STRs) show that in December 2005 the Veteran was referred for evaluation of right sided epistaxis. The Veteran reported epistaxis for the past two years which began after being started on Coumadin used to treat his DVT. Episodes reportedly occurred several times during the week. In February 2006, the Veteran filed a service connection claim for epistaxis. The Veteran underwent a VA examination in February 2006. The examiner noted the Veteran was taking Coumadin and that he had a history of frequent nose bleeds due to his use of that medication. Nose bleeds were reported 7 times per week. The examiner also noted the Veteran came to the examination following a right nasal passage cauterization. Gauze was present in the right naris and the Veteran was noted to be on bacitracin to help decrease the amount of nose bleeds. He was diagnosed with a history of epistaxis. A February 2006 ENT clinic record shows that the Veteran underwent a cautery of epistaxis that was noted as secondary to Coumadin use. In February 2006, the Veteran was also treated for chronic epistaxis. The physician noted the Veteran was status post nitrate cautery and was doing well until the following night when he experienced right sided epistaxis. The physician noted that the Veteran's international normal ratios (for anticoagulant monitoring) (INR) was found to be 4.9 and the Veteran's recurrent epistaxis was found most likely due to the elevated INR. An October 2006 rating decision granted service connection for allergic rhinitis and epistaxis. Both disabilities were combined and assigned a non-compensable rating effective September 1, 2006. However, the Veteran did not separate from service until August 2010. Therefore, an October 2006 VA Form 21-8947 was issued showing that disability payments were disallowed as the Veteran was currently on active duty. Thereafter, STRs show the Veteran's epistaxis was treated with bacitracin zinc ointment in December 2006. In July 2009, the Veteran was noted to have had a couple recent nosebleeds. In December 2009, the Veteran was noted to have epistaxis with infrequent nose bleeds that subsided after a short while. The epistaxis was found most likely due to dry winter air and the Veteran was treated with saline nasal washings. In May 2010, the Veteran was seen for epistaxis that had been ongoing due to use of Coumadin for nearly 7 years. The physician noted past treatment with silver nitrate and electrocautery in 2005 and 2006 with no permanent resolution of his symptoms. The Veteran reported using Vaseline ointment in his nose without success. Upon examination, the physician noted dried crusted blood and mucus in the right nasal septum which was removed revealing a small ulceration with some bleeding. The Veteran was diagnosed with recurrent right-sided epistaxis related to chronic crusting as well as his treatment with Coumadin. The Veteran was treated with a small dressing of Surgicel over the area and given saline nasal mist. A June 2010 VA ENT medical record noted a problem with recurrent epistaxis. The physician noted a small ulceration on the right side of the caudal septum during the previous visit. The Veteran reported no bleeding the past 10 to 14 days. The ulcer was noted as currently partly healed and the Veteran was diagnosed with improving recurrent epistaxis. Another June 2010 VA medical record noted a provisional diagnosis for epistaxis In July 2010, the Veteran again filed for service connection for chronic epistaxis and allergic rhinitis. An August 2010 STR shows the Veteran reported epistaxis and that he decreased his medication dosage because of a heavy nosebleed. The Veteran underwent a VA examination in August 2010. The Veteran reported being diagnosed with epistaxis which had existed for over 5 years. The Veteran also reported sinus problems, ulceration of his nostril and heavy bleeding. Bleeding reportedly occurred several times per week and he had been treated for nasal ulcerations including cauterization twice with cellulose patch. He was not taking medication for his condition. The examiner noted no nasal obstruction, deviated septum, nasal polyps, scar or disfigurement, or partial loss of the nose or ala. The examiner diagnosed the Veteran with recurrent epistaxis secondary to Coumadin therapy. The examiner noted subjective factors consisting of recurrent nose bleeds with currently absent objective factors. Post-service medical records show that in March 2012 the Veteran was diagnosed with ongoing recurrent episodes of epistaxis. The last episode was reported two weeks prior. The Veteran was referred to ENT for further evaluation. Thereafter, a March 2012 VA ENT medical record shows the Veteran reported a recent history of chronic right sided epistaxis that occurred spontaneously for several years. The physician noted the Veteran took Coumadin due to a history of potential pulmonary emboli, had bad seasonal allergies and that he stopped use of vaporizing treatment. The Veteran reported using Vaseline in his nasal passage. The physician performed an endoscopy examination of the Veteran's nasal passages which revealed a large crusted area on the right side sitting over Kiesselbach's spots. No active bleeding was found and the Veteran did not report bleeding for several days. The VA physician diagnosed the Veteran with epistaxis and told the Veteran the area where the crusting and bleeding occurred needed to be settled down. The Veteran was treated with antibiotic ointment and a cotton plug. Additionally, the physician noted that the pathophysiology of his nose bleed was discussed with the Veteran and that he was going to the hematology clinic to see if they could change his blood thinner medication from Coumadin which might help his nosebleeds. In his January 2013 letter enclosing his VA Form 9, Substantive Appeal, the Veteran asserted that his epistaxis was a chronic condition resulting in spontaneous nose bleeds several times each week that had continued since service and which continued to be treated. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110, 1131 (2012); Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that interpretation of section 1110 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). For VA purposes, a current disability exists when a claimant has a disability at the time a claim is filed or at some point during the pendency of that claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that the requirement of the existence of a current disability is satisfied when a Veteran has a disability at the time he/she files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim). In the present case, there is sufficient evidence the Veteran meets the threshold criterion for service connection of a current disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). Specifically, during the pendency of the claim, a March 2012 VA medical record shows the Veteran was diagnosed and treated for ongoing recurrent episodes of epistaxis. Thus, the Veteran clearly has current diagnoses and the remaining question is whether his epistaxis is related to service. 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; or, for any increase in severity of a nonservice-connected disease or injury which is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of nonservice-connected condition. 38 C.F.R. § 3.310(a), (b). 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). In this regard, the Board notes that the medical evidence of record supports a finding that the recurrent epistaxis is secondary to the use of prescribed Coumadin used to treat the Veteran's service-connected status post DVT with post phlebitis syndrome. Specifically, an August 2010 VA examiner diagnosed the Veteran with recurrent epistaxis secondary to Coumadin therapy. A March 2012 VA ENT medical record also supports this finding as the physician referred the Veteran to a VA hematology clinic to see if a change in blood thinner medication from Coumadin might help his condition. Lastly, the Board recognizes the October 2006 rating decision that granted service connection for epistaxis which was noted to have begun after starting on Coumadin. Additionally, the October 2006 rating decision noted that chronic rhinitis, a condition for which the Veteran is also service-connected, reportedly aggravated his epistaxis. Thus, the Board concedes that the Veteran's epistaxis is secondary to his use of Coumadin therapy. Accordingly, the Board finds the criteria for service connection on a secondary basis for epistaxis have been met. The claim is granted. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017). ORDER Entitlement to service connection for epistaxis, claimed as secondary to service-connected status post DVT with post phlebitis syndrome, is granted ____________________________________________ Kelli A. Kordich Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs