Citation Nr: 1804259 Decision Date: 01/22/18 Archive Date: 01/31/18 DOCKET NO. 13-03 002 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to service connection for psoriatic arthritis, to include as secondary to service-connected generalized anxiety disorder with posttraumatic stress disorder (PTSD) symptoms and related depression. 2. Entitlement to service connection for hypertension, to include as secondary to service-connected generalized anxiety disorder with PTSD symptoms and related depression. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Costello, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1964 to May 1967. This matter comes before the Board of Veterans Appeals (Board) on appeal from a July 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York. In August 2014, the Veteran testified before a Veterans Law Judge (VLJ) at a hearing in Washington, D.C. In July 2017, the Veteran was informed that the VLJ who held the August 2014 hearing was no longer employed by the Board, and he was given an opportunity to appear at another hearing. 38 C.F.R. § 20.707 (2017). In August 2017, the Veteran stated that he did not want another hearing. This matter was previously before the Board and was remanded for further development in March 2015. There has been substantial compliance with the Board's remand directives. Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141, 147 (1999) (requiring substantial compliance with Board remand directives). The case is now returned for appellate review. FINDINGS OF FACT 1. Psoriatic arthritis is not attributable to or related to service. 2. Hypertension is not attributable to or related to service. 3. The record fails to demonstrate competent evidence that the service-connected generalized anxiety disorder with PTSD symptoms and related depression caused or aggravated the Veteran's psoriatic arthritis or hypertension. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for psoriatic arthritis have not been met. 38 U.S.C. §§ 1101, 1110 (2012); 38 C.F.R. §§ 3.303, 3.304. 3.306, 3.310 (2017). 2. The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C. §§ 1101, 1110 (2012); 38 C.F.R. §§ 3.303, 3.304. 3.306, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) VA has a duty to assist the Veteran in obtaining potentially relevant records, and providing an examination or medical opinion when necessary to make a decision on the claim. Here, the Veteran's service treatment records (STRs), VA records, and identified private treatment records have been obtained and associated with the record. VA has provided medical examinations concerning the issues on appeal. When VA provides a claimant an examination or obtains a medical opinion, VA must ensure the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). However, unless the claimant challenges the adequacy of the examination or opinion, the Board may assume, and need not affirmatively establish, the adequacy of the examination report and the competence of the examiner. Sickels v. Shinseki, 643 F.3d. 1362 (Fed. Cir. 2011) (while Board is required to consider issues independently raised by the evidence of record, Board is still entitled to assume the competency of a VA examiner and the adequacy of a VA opinion without demonstrating why examiner's report is competent and sufficiently informed); Rizzo v. Shinseki, 580 F.3d 1288 (Fed. Cir. 2009). Here, in June and November 2017 statements, the Veteran's representative generally asserted that the May 2017 VA examiner was not competent to diagnose the Veteran. Mere allegation of inadequacy, without more, does not warrant an additional examination. See Sickels, 643 F.3d 1365-66 (Fed. Cir. 2011) (holding that although the Board is required to consider issues independently raised by the evidence of record, the Board is still "entitled to assume" the competency of a VA examiner and the adequacy of a VA opinion without "demonstrating why the medical examiners' reports were competent and sufficiently informed"). Even when the claimant challenges a VA examination or opinion, the Board may assume the competency of the VA medical examiner as long as, under 38 C.F.R. § 3.159 (a)(1), the examiner is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Cox v. Nicholson, 20 Vet. App. 563 (2007). The Board finds that the reports of the examination and the provided opinions provide the information needed to fairly decide the claim for entitlement to service connection for psoriatic arthritis and hypertension. The examiner reviewed the claims file, examined the Veteran, and described the disability in sufficient detail to enable the Board to make a fully informed decision on the claims. D'Aries v. Peake, 22 Vet. App. 97 (2008) (examination is adequate when it is based on consideration of the claimant's medical history and describes the disability in sufficient detail so the Board's evaluation of the disability will be a fully informed one); Monzingo v Shinseki, 26 Vet. App. 97 (2012) (examination reports are adequate when, as a whole, they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for the opinion, even when the rationale does not explicitly lay out the examiner's journey from the facts to a conclusion); Acevedo v. Shinseki, 25 Vet. App. 286 (2012) (the law imposes no reasons-or-bases requirement on examiners). The examiner specifically acknowledged and discussed what the medical evidence of record did and did not show in connection with the present claim. There are no apparent inconsistencies or ambiguities in the examination report. The Board, in its own lay capacity, is not otherwise qualified to call into question the VA examiner's medical judgment, nor does the Board find any reason to do so. Monzingo v Shinseki, 26 Vet. App. 97 (2012). As the examination and opinions have sufficiently informed the Board of both the examiner's judgment on the medical questions at issue and the essential rationale for the opinions made, the Board finds that the May 2017 VA examination is adequate. The Veteran was provided with VA examinations which contained descriptions of the history of the disabilities at issue; documented and considered the relevant medical facts and principles; and provided opinions regarding the etiology of the Veteran's claimed conditions. VA's duty to assist with respect to obtaining relevant records and examination has been met. 38 C.F.R. § 3.159(c); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Finally, the Veteran testified at a Board hearing. The hearing was adequate as the Veterans Law Judge who conducted the hearing explained the issues and identified possible sources of evidence that may have been overlooked. In summary, the Board finds that it is difficult to discern what additional guidance VA could have provided to the Veteran regarding what further evidence should be submitted to substantiate the claim. Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004); see also Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc) (observing that "the VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims."); Reyes v. Brown, 7 Vet. App. 113, 116 (1994); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (both observing circumstances as to when a remand would not result in any significant benefit to the Veteran). Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1153; 38 C.F.R. §§ 3.303, 3.304, 3.306. In addition, arthritis and hypertension will be presumed to have been incurred in or aggravated by service if it had become manifest to a degree of 10 percent or more within one year of a Veteran's separation from service. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With chronic diseases shown as such in service or within the presumptive period so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clearcut clinical entity, at some later date. Continuity of symptomatology is required only where the condition noted during service or the presumptive period is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after service is required to support the claim. 38 C.F.R. § 3.303(b). This regulation pertains to "chronic diseases" enumerated in 38 C.F.R. § 3.309(a) (listing named chronic diseases). Walker v. Shinseki, 708 F.3d 1331, 1336-37 (Fed. Cir. 2013). The United States Court of Appeals for the Federal Circuit (Federal Circuit) noted that the requirement of showing a continuity of symptomatology after service is a "second route by which a veteran can establish service connection for a chronic disease" under subsection 3.303(b). Walker, supra. Showing a continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during the] presumptive period." Id. (holding that section 3.303(b) provides an "alternative path to satisfaction of the standard three-element test for entitlement to disability compensation"). 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, service connection may be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the of the nonservice-connected disease, will be service-connected. 38 C.F.R. § 3.310(b). Secondary service connection under § 3.310 entails "any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition." Allen v. Brown, 7 Vet. App. 439, 448 (1995). Accordingly, in order to establish entitlement to service connection on a secondary basis, the evidence must show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id. VA will not find that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (b). The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 C.F.R. part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. Id. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Reasonable doubt concerning any matter material to the determination is resolved in the Veteran's favor. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The Veteran contends that he developed psoriatic arthritis and hypertension secondary to his service-connected generalized anxiety disorder with PTSD symptoms and related depression. His STRs do not show complaints of, treatment for, or a diagnosis of hypertension or psoriatic arthritis. His March 1964 entrance examination and May 1967 separation examination revealed normal findings and his recorded blood pressures were 114/74 and 88/64, respectively. Post-service, in April 2001, the Veteran was diagnosed with psoriatic arthritis after the Veteran fell down stairs. A September 2010 VA treatment note stated that the Veteran was diagnosed with psoriatic arthritis twenty years earlier and was treated with nonsteroidal anti-inflammatory agents. The Veteran reported a history of hypertension and had a blood pressure reading of 128/70. The VA physician found that the psoriatic arthritis was reasonably stable. In June 2012, the Veteran underwent a VA disability benefits questionnaire (DBQ) for hypertension. The Veteran's claims file was reviewed. He was diagnosed with hypertension in March 2009. The Veteran reported that his elevated blood pressures were gradual, that he was never hospitalized, and he used medication daily to control his blood pressure. His diastolic blood pressure was not predominantly 100 or more. He had the following blood pressure readings 110/70 in April 2012, 110/64 in December 2011, and 121/61 in June 2011. The examiner opined that it was less likely than not (less than 50% probability) that the Veteran's service-connected generalized anxiety disorder with PTSD symptoms and related depression aggravated (increased in disability beyond the natural progression) his hypertension. He reasoned that medical literature found that mental diseases and stress can temporarily elevate blood pressure during an acute phase of the disease, but it does not permanently elevate blood pressure. An April 2010 cardiology record found that the Veteran had a family history of premature coronary disease. Further, medical literature found that anxiety and stress did not cause long-term high blood pressure. The examiner found that the Veteran's PTSD symptoms were not a proximate cause of his chronic essential hypertension nor was it an aggravating factor; however, his hypertension is more likely related to atherosclerosis from genetic factors. Also in June 2012, the Veteran underwent a VA DBQ for psoriatic arthritis. The Veteran's claims file was reviewed. He was diagnosed with psoriatic arthritis. The Veteran reported that he developed psoriasis approximately 24 years earlier and that developed into psoriatic arthritis, which caused pain in his joints. He reported taking medication daily for pain. On examination, The Veteran reported pain in his spine, bilateral shoulders, hips, elbows, knees, wrists, ankles, hands, and feet. He had at least a 50 percent reduction in range of motion on all the above listed joints. Due to his arthritis condition, the Veteran was totally incapacitated for less than a week in the past year. He had general fatigue, a fever, sweats, chills, and pain. He regularly used orthotic shoes and occasionally used a cane and brace. The examiner opined that it was less likely than not (less than 50% probability) that the Veteran's service-connected generalized anxiety disorder with PTSD symptoms and related depression aggravated (increased in disability beyond the natural progression) his psoriatic arthritis. He rationed that known and accepted medical literature states that PTSD symptoms are not a proximate cause of psoriatic arthritis, nor has it been established as an aggravating factor in the development of such. Based on medical literature, the cause of psoriatic arthritis is unknown but appears linked to genetic factors and family history. The Veteran's private medical records indicated that he has a history of autoimmune disease. In October 1995, he stated that a daughter had rheumatoid arthritis. A March 2008 treatment note recorded a strong family history of autoimmune disease, with one daughter having rheumatoid arthritis and another daughter being followed for an autoimmune disorder. In January 2013, the Veteran's VA physician threating his psoriatic arthritis opined that the Veteran's psoriatic arthritis was more likely than not activated by continual stress he has from his service-connected PTSD. No rationale was provided. At his June 2014 hearing, the Veteran asserted that his hypertension and psoriatic arthritis were related to his service-connected generalized anxiety disorder. He reported that he developed high blood pressure in the past few years and that he was diagnosed with psoriatic arthritis 25 to 30 years earlier. In September 2014, the Veteran's family physician that had treated him for over twenty years opined that it was more likely than not that the Veteran's PTSD symptoms aggravated his psoriatic arthritis and hypertension. She stated that PTSD was already established as a service-connected condition and she did not know of any other risk factors that may have precipitated his current condition. Studies found that people with PTSD were more likely to develop arthritis and other chronic diseases, including cardiovascular disease. Also, she opined that his increased stress is more likely than not related to PTSD, yet she also stated that psoriatic arthritis patients also experience inner body stressors. A March 2015 VA treatment note revealed that the Veteran's psoriatic arthritis was well controlled. The Veteran reported a significant life-long accumulation of sun exposure. In May 2017, the Veteran underwent another VA DBQ for hypertension and psoriatic arthritis. The VA examiner opined that the Veteran's hypertension and psoriatic arthritis was less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service-connected generalized anxiety disorder with PTSD symptoms and related depression. The examiner conducted a comprehensive review of the Veteran's claims file, blood pressure readings, and pulse readings. The VA examiner stated that increased pulse readings in association with surges in blood pressure readings could be consistent with sympathetic overactivity from a variety of causes such as pain, stress, etc.; however, there were no such increased pulse readings recorded in the comprehensive vital sign records. Extensive review of the vital sign records of blood pressure and pulse readings from 2010 to 2017 did not show evidence of increased sympathetic overactivity. The Veteran's many pulse readings are well within the normal range (less than 100 beats per minutes) and do not show evidence of sympathetic overactivity. His blood pressure readings also show great stability. The VA examiner concluded that the objective evidence did not support Veteran's private medical opinion that his PTSD causes increased sympathetic nervous system over activity, which worsens his hypertension. Further the private physician stated that the Veteran's PTSD symptoms caused sleep deprivation which aggravated his hypertension. No objective evidence supported this assertion as the Veteran's blood pressure readings over years are well controlled with stability. His medical records showed that his sleep disorder is caused by sleep apnea. Sleep apnea is not caused by PTSD symptoms, yet is a risk factor for hypertension. Further, the Veteran had a family history of premature coronary disease and medical literature found that anxiety and stress did not cause long-term high blood pressure. Also, review of the Veteran's blood pressure and pulse readings revealed that there was no elevation in sort-term pulse and blood pressure readings. Hypertension is extremely common in the general population of adults and the Veteran has significant risk factors that are not related to his PTSD symptoms. Additionally, the VA examiner did not find evidence that the Veteran's service-connected generalized anxiety disorder with PTSD symptoms and related depression caused his psoriatic arthritis or aggravated its natural progression. Psoriatic arthritis occurs when the body's immune system attacks healthy cells. The abnormal immune response causes inflammation in joints. It is not clear why the immune system turns on healthy tissue, but genetic or environmental factors have been found to be causes. Scientists also know that not everyone who inherits the genes for psoriasis will get psoriasis or psoriatic arthritis. Studies found that a person must inherit the right mix of genes, and then the person must be exposed to a trigger. A virus or bacteria in the environment are known environmental triggers for psoriatic arthritis, which would not be related to the Veteran's service connected condition. The Veteran's private doctor did not reference any specific medical literature to support her assertion. The American Academy of Dermatology has not determined the cause of psoriasis or psoriatic arthritis, but compiled a list of common psoriasis triggers, such as: a stressful event, strep throat, taking certain medicine, dry weather, or sunburn. The list is described as anecdotal as opposed to scientifically established, which is an insufficient basis to establish the Veteran's PTSD symptoms to his psoriatic arthritis. In June 2017, the Veteran underwent a private DBQ for psoriatic arthritis. He was diagnosed with psoriatic arthritis and reported symptoms for over thirty years. His pain and limitation of movement were not evaluated. The examiner found that bilateral foot deformities were attributable to his arthritis. The examiner noted that he only saw the Veteran for the examination and that he did not recall if the Veteran used assistive devices. No imaging studies or laboratory studies were reviewed or performed. The examiner found that the Veteran had global arthritic dysfunction, but could regain a degree of function with treatment. The Board must weigh the credibility and probative value of the medical opinions, and in so doing, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998). The Board must account for the evidence it finds persuasive or unpersuasive, and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). In determining the weight assigned to this evidence, the Board also looks at factors such as the health care provider's knowledge and skill in analyzing the medical data. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also Black v. Brown, 10 Vet. App. 279, 284 (1997). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). 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; 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."). The failure of the January 2013 physician to provide a basis for his opinion goes to the weight or credibility of the evidence. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). The Court has further recognized that a mere statement of opinion, without more, does not provide an opportunity to explore the basis of the opinion. See Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). Further, the June 2017 private DBQ for psoriatic arthritis did not provide a nexus opinion. The VA examiner's opinion was based on review of the Veteran's claims file and included an examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Further, she included citations of medical literature to support her findings. As stated above, the September 2014 private physician did not support her findings with citations to studies; while the VA examiner listed the studies used and recorded the objective evidence used for her findings, such as blood pressure/pulse readings and the Veteran's family history. The VA examiner's opinion, rendered by a medical professional, is afforded significant probative weight. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (holding that the probative value of medical opinion evidence is based on the personal examination of the patient, the knowledge and skill in analyzing the data, and the medical conclusion reached); see also Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is factually accurate, fully articulated, and has sound reasoning for the conclusion.) The Board assigns this opinion great probative weight, as it was based on examination of the Veteran. The Veteran's record, and included a rationale for the conclusions. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Black v. Brown, 10 Vet. App. 279, 284 (1997). The Board has carefully considered the articles from the internet providing information about hypertension and psoriatic arthritis in relation to PTSD, anxiety, and depression. Medical treatise evidence can provide important support when combined with the pertinent opinion of a medical professional. Similarly, medical treatise evidence could "discuss generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least a plausible causality based upon objective facts." Mattern v. West, 12 Vet. App. 222, 229 (1999); Wallin v. West, 11 Vet. App. 509 (1998). Here, the aforementioned information is simply too general to make a causal link more than speculative in nature, or to outweigh the specific medical evidence in this case which is directly pertinent to the Veteran. The Board has considered the Veteran's own opinion that his service-connected generalized anxiety disorder with PTSD symptoms and related depression caused his hypertension and psoriatic arthritis. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay testimony is competent as to matters capable of lay observation, but not with respect to determinations that are "medical in nature." Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). The Veteran is competent in this case to report his symptoms, but nothing in the record demonstrated that he has received any special training or acquired any medical expertise in evaluating and determining causal connections for the claimed condition. Therefore, a medical expert opinion would be more probative regarding the causation question in this case and has been obtained as set forth above. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Thus, the Veteran's opinion is outweighed by the findings to the contrary by the VA examiner, a medical professional who considered the pertinent evidence of record and found against such a relationship. See id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation). The most probative evidence establishes that psoriatic arthritis and hypertension are not related to service or secondary to the Veteran's service-connected generalized anxiety disorder with PTSD symptoms and related depression. Accordingly, service connection is not warranted. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The preponderance is against the Veteran's claim, and it must be denied. ORDER Service connection for psoriatic arthritis, to include as secondary to service-connected generalized anxiety disorder with PTSD symptoms and related depression, is denied. Service connection for hypertension, to include as secondary to service-connected generalized anxiety disorder with PTSD symptoms and related depression, is denied. ______________________________________________ M. Tenner Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs