Citation Nr: 1804331 Decision Date: 01/23/18 Archive Date: 01/31/18 DOCKET NO. 11-20 092 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for erectile dysfunction (ED), to include as secondary to service-connected orthopedic disabilities and medication taken for service-connected orthopedic disabilities. 2. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected orthopedic disabilities and medication taken for service-connected orthopedic disabilities. REPRESENTATION Appellant represented by: Virginia Department of Veterans Services ATTORNEY FOR THE BOARD C. Casey, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1981 to August 1987 and from December 1987 to October 1990. This case comes before the Board of Veterans' Appeals (Board) on appeal of a November 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. In January 2017, the Board remanded this case to obtain additional VA medical opinions. The requested medical opinions having been provided, the directives have been substantially complied with and the matter again is before the Board. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). In an August 2016 submission, the Veteran's representative offered argument in favor of an increased rating for the Veteran's service-connected right hip disability. This issue was denied in a May 2011 rating decision; the Veteran filed a notice of disagreement, but did not perfect the appeal after the statement of the case was issued. Therefore, that issue is not now before the Board. FINDINGS OF FACT 1. The preponderance of the evidence of record is against a finding that the Veteran's ED is causally related to his active service, or was caused or aggravated by the Veteran's service-connected orthopedic disabilities. 2. The preponderance of the evidence of record is against a finding that the Veteran's GERD is causally related to his active service, or was caused or aggravated by the Veteran's service-connected orthopedic disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for ED have not been met. 38 U.S.C. §§ 1101, 1110, 1154 (2012); 38 C.F.R. § 3.303, 3.304, 3.310 (2017). 2. The criteria for service connection for GERD have not been met. 38 U.S.C. §§ 1101, 1110, 1154 (2012); 38 C.F.R. § 3.303, 3.304, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Legal Criteria 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). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006). Analysis The Veteran seeks service connection for ED and GERD, to include as secondary to residuals of the Veteran's service-connected orthopedic disabilities. The Veteran's available service treatment records do not show any symptoms, treatment, or diagnosis of ED or GERD while in service. Post-service, VA treatment records reflect that the Veteran has been diagnosed with ED and GERD since 2004. However, the medical records do not demonstrate that any medical professional has ever indicated that his ED or GERD either had their onset or may have been directly related to active duty service. Indeed, a June 2017 VA examiner determined that the Veteran's ED is less likely as not related to his active service. She explained that the ED was most likely due to natural age and elevated body mass index (BMI), and that the medical literature supported natural age and BMI as the risk factors in the Veteran's case with the highest predictive value. The June 2017 examiner also opined that the Veteran's GERD is less likely as not related to his active service. She noted that the Veteran had suspected peptic ulcer disease on active duty that resolved, but that this condition was not the same as GERD. She explained that the Veteran's GERD was most likely due to natural age, strong genetic predisposition to hypersecretion of stomach acid, and dietary choices exacerbated by elevated BMI. The Board finds the June 2017 VA examiner's opinions to be entitled to great probative weight. This opinion was provided after an examination of the Veteran and a review of the updated claims file. The examiner provided an adequate rationale for the conclusions reached based on the medical record, the examination findings of record, and medical literature. Monzingo v. Shinseki, 26 Vet. App. 97 (2012) (examination reports are adequate when they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion). Therefore, service connection is not warranted on a direct basis. A disability may also be service connected on a secondary basis if it is proximately due to or the result of a service-connected disease or injury; or, if it is aggravated by a service-connected disease or injury. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.310 (a), (b). The question for the Board is whether the Veteran's ED or GERD are etiologically related to, or aggravated by, the Veteran's service-connected disabilities. The Veteran contends that his ED and GERD are a result of medications he takes for his service-connected orthopedic disabilities. See Statement of Accredited Representation in Appealed Case, received August 5, 2016. The Board notes that the Veteran has been found entitled to service connection for orthopedic disabilities of the lumbar spine, right hip, and bilateral knees. VA treatment records show that the Veteran has taken NSAIDS (nonsteroidal anti-inflammatory drugs, a type of pain medication, also referred to as NSAIA) to treat these disabilities. In October 2009, private physician Dr. M.C. noted that the Veteran has GERD and took NSAIDS while in the military, and since then, for his knee pain. Dr. M.C. noted that NSAIDS can cause GERD, and opined that it was highly probable that the Veteran's GERD was caused by NSAIDS use. No other rationale was provided other than the possibility than NSAIDS can cause GERD. In April 2010, a VA examination was conducted to assess the existence and etiology of the Veteran's ED and GERD. In the April 2010 examination report, and in an April 2010 addendum opinion, the examiner concluded that the Veteran's ED and GERD were not related to his service-connected orthopedic disabilities because there was no ED or GERD documented in the Veteran's military medical records. In an April 2011 addendum opinion, the VA examiner found that the Veteran's ED was not caused by medication taken for the Veteran's service-connected disabilities because the pain medications do not cause ED, and because the Veteran does not have a diagnosis of intervertebral disc syndrome (IVDS), which would cause ED. The April 2011 examiner also found that the Veteran's GERD was not caused by the Veteran's pain medication. The VA examiner reasoned that the Veteran's GERD was manifested by the symptom of reflux, which is not caused by NSAIDS, as opposed to the symptom of gastritis, which is caused by NSAIDS. In January 2017, the Board remanded these matters for further development. The Board determined that the April 2010 and April 2011 VA opinions did not adequately address the question of etiology. The Board found these opinions were inadequate because they only addressed causation, and did not address whether the Veteran's disabilities were aggravated by the service-connected disabilities. Per the Board remand, another VA examination was conducted in March 2017. The March 2017 VA examiner concluded that the Veteran's ED was less likely than not caused or aggravated by his service-connected musculoskeletal disabilities or medication. The examiner explained that ED is mainly linked to vascular or hormonal factors, and the pathologies of his ED and musculoskeletal disabilities are not in any way related. The March 2017 VA examiner also concluded that the Veteran's GERD was less likely than not caused or aggravated by his service-connected musculoskeletal disabilities or medication. The examiner indicated that the pathologies of the Veteran's GERD and musculoskeletal disabilities are not in any way related. The examiner cited medical records which show that the Veteran still suffered from esophagitis after he stopped taking NSAIDS, which supports a conclusion that the two are unrelated. The examiner considered the October 2009 private medical opinion that GERD was caused by NSAIDS, but found that medical literature did not support this conclusion. In June 2017, another VA examiner opined that the Veteran's GERD was less likely than not caused or aggravated by his service-connected musculoskeletal disabilities or medication. She also noted that when the NSAIDS were discontinued, the Veteran's GERD did not resolve. While NSAIDS are documented in the literature to exacerbate symptoms of GERD, in this case, the examiner found that the etiology of GERD was instead consistent with natural age, strong genetic predisposition to hypersecretion of stomach acid, and dietary choices exacerbated by elevated BMI. She also found that there was no objective evidence in the record to show chronic or permanent aggravation of the Veteran's GERD by the NSAIDS. The Board finds the March 2017 and June 2017 VA examiners' opinions to be entitled to great probative weight. These opinions were provided after an examination of the Veteran and a review of the updated claims file. The examiners addressed the Veteran's assertions as to the origins of his ED and GERD, and the VA examiners provided an adequate rationale for the conclusions reached based on the medical record, the examination findings of record, and medical literature. Monzingo v. Shinseki, 26 Vet. App. 97 (2012) (examination reports are adequate when they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion). The Board finds that the October 2009 private medical opinion is lacking in significant probative value. See Prejean v. West, 13 Vet. App. 444 (2000) (factors for determining probative value of medical opinions include their thoroughness and detail, whether they discussed why contrary opinions were not persuasive, and the opinion-writer's access to relevant records). In rendering this opinion, the private physician provided no other rationale other than the fact that NSAIDS can cause GERD. Without any additional explanation, it appears the private physician's opinion is based on the mere possibility of an etiological relationship between the Veteran's GERD and his medication, and as such, amounts to speculation. It is not clear that the private physician reached this medical opinion by applying sound medical principles to a review of all important evidence. The Board acknowledges the Veteran's belief that his ED or GERD were caused or aggravated by residuals of his service-connected back, hip, and bilateral knee disabilities. The Veteran is competent to provide testimony concerning factual matters of which he has first-hand knowledge (i.e., experiencing symptoms either in service or after service). See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). However, as a layperson without the appropriate medical training and expertise, the Veteran is simply not competent to provide a probative opinion on a complex medical matter, such as an etiological relationship between any current disability and military service or a service-connected disability. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Based on the given facts, the preponderance of the evidence is against a finding that the Veteran's ED and GERD are etiologically related to or aggravated by his service-connected orthopedic disabilities, or by the side-effects of his medication for orthopedic disabilities. Thus, service connection for such cannot be granted. In sum, the Board finds that the preponderance of the evidence is against the Veteran's claims seeking service connection for ED and GERD. As the preponderance of the evidence weighs against the Veteran's claims, the benefit-of-the-doubt rule does not apply and the claims must be denied. 38 U.S.C. §5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for ED is denied. Entitlement to service connection for GERD is denied. ____________________________________________ JENNIFER HWA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs