Citation Nr: 1804352 Decision Date: 01/23/18 Archive Date: 01/31/18 DOCKET NO. 13-10 650 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for coronary artery disease. 2. Entitlement to service connection for residuals of gallbladder removal, to include surgical scars. 3. Entitlement to service connection for gastroesophageal reflux disease (GERD), claimed as a hernia. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. I. Tissera, Associate Counsel INTRODUCTION The Veteran had active service from June 1966 to March 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal of an August 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. When this case was last before the Board in June 2016, it was remanded for further development. FINDINGS OF FACTS 1. The evidence of record does not establish that the Veteran's coronary artery disease was incurred in or caused by his service. 2. The evidence of record does not establish that the Veteran's residuals of gallbladder removal were incurred in or caused by his service. 3. The evidence of record does not establish that the Veteran's GERD was incurred in or caused by his service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for coronary artery disease has not been met. 38 U.S.C. §§ 1110, 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 2. The criteria for entitlement to service connection for residuals of gallbladder removal, to include surgical scars, has not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2017). 3. The criteria for entitlement to service connection for GERD has not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. §§ 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The duty to notify has been met. Neither the Veteran nor his representative has alleged prejudice with regard to notice. The Federal Court of Appeals has held that "absent extraordinary circumstances... it is appropriate for the Board and the Veterans Court to address only those procedural arguments specifically raised by the veteran...." Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). In light of the foregoing, nothing more is required. The duty to assist includes assisting the claimant in the procurement of relevant records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). The RO associated the Veteran's service and VA treatment records with the claims file. All released or submitted private treatment records have been associated with the claims file. No other relevant records have been identified and are outstanding. As such, the Board finds VA has satisfied its duty to assist with the procurement of relevant records. The duty to assist also includes providing a medical examination or obtaining a medical opinion when necessary to make a decision on a claim, as defined by law. 38 C.F.R. § 3.159(c)(4). In this case, the Veteran was provided with a VA examination in March 2010 with an addendum in April 2010. The examination was adequate. The examiner reviewed the medical evidence of record in conjunction with the examination, and conducted a thorough medical examination of the Veteran. The Veteran's pertinent symptomatology was recorded sufficiently to accurately adjudicate the claim. Based on the foregoing, the Board finds the examination report to be thorough, complete, and sufficient base upon which to reach a decision on the Veteran's claim. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Barr v. Nicholson, 21 Vet. App. 303 (2007). Since VA has obtained all relevant identified records and provided an adequate medical examination, its duty to assist in this case is satisfied. II. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Disability which is proximately due to or the result of service-connected disease or injury shall be service-connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Secondary service connection may be established by a showing that a nonservice-connected disability is caused or aggravated (chronically worsened) by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). A. Coronary Artery Disease The Veteran contends he is entitled to service connection for his coronary artery disease. The Veteran's service treatment records (STRs) show that on his February 1966 entrance exam, the Veteran reported pain or pressure in his chest, his heart palpitating or pounding, low blood pressure, and frequent indigestion. The Veteran reported similar symptoms on the February 1969 separation exam, citing pain or pressure in his chest, frequent indigestion, frequent or severe headaches, and dizziness or fainting spells. As for the chest pains and indigestion, the physician noted dietary issues, but no symptoms present at the time of discharge. None of the Veteran's STRs show any evidence of complaints, treatment, or diagnosis for coronary artery disease. The Veteran's treatment records from the Orlando Heart Center indicated the Veteran had a successful stent implantation surgery in September 1995. A treatment note from May 1996 indicated that the Veteran had a known history of coronary artery disease beginning with angina in September 1995. The Veteran was afforded a VA examination in March 2010. The Veteran reported the onset of his coronary artery disease as 1994 and had a stent inserted. The course of the disease has been stable since the onset. The examiner stated that her review of the claims file was not helpful. While she noted chest pains in the STRs prior to entering military service, there was no EKG record or an evaluation indicating that the chest pains had been resolved. The examiner also noted no chronicity between the Veteran's discharge from service in 1966 to the diagnosis of coronary artery disease in the 1994. Based on her review, the examiner found she could not resolve the issue without resorting to mere speculation. The Board notes that when a medical examiner concludes that she is unable to provide a nexus opinion without speculation, this alone does not make the medical opinion inadequate; a medical opinion with such language may be adequate if the examiner sufficiently explains the reasons for this inability. Jones v. Shinseki, 23 Vet. App. 382 (2010). Even though the examiner used the phrase "mere speculation," the Board finds that it does not indicate that she was unable to make appropriate conclusions with accompanying rationale. Here, the examiner opined that the Veteran's current coronary artery disease was not related to service. Reading the opinion as a whole reflects the examiner acknowledged the Veteran's assertions regarding his diagnosis in 1994, referenced the STRs, the lack of complaints during service, and noted that there was no medical documentation to establish a nexus to support any clinically diagnosed coronary artery disease between 1966 and 1994, as reasoning for why it was less likely than not the coronary artery disease was incurred in service. Thus, she was able to offer an opinion on the relevant question. The Board finds the March 2010 VA examiner's explanation to be sufficient and concludes that the opinion and rationale are competent and credible and provide probative evidence. The claims folder contains no competent medical evidence refuting this opinion. Here, coronary artery disease was not noted, diagnosed or manifest during service or within one year of separation. In addition, he did not have characteristic manifestations sufficient to identify the disease entity during that time frame. Although he reported a history of chest pressure or pain at separation, the heart, vascular system and chest X-ray film were normal and blood pressure was 120/78. His complaints were attributed to indigestion rather than cardiac pathology. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable in the instant appeal. 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert, 1 Vet. App. at 55-57. B. Gallbladder Removal The Veteran contends he is entitled to service connection for residuals of gallbladder removal, to include surgical scars. As stated above, the Veteran's STRs show that on his February 1966 entrance exam, the Veteran reported pain or pressure in his chest, his heart palpitating or pounding, low blood pressure, and frequent indigestion. The Veteran reported similar symptoms on the February 1969 separation exam, citing pain or pressure in his chest, frequent indigestion, frequent or severe headaches, and dizziness or fainting spells. As for the chest pains and indigestion, the physician noted dietary issues, but no symptoms present at the time of discharge. None of the Veteran's STRs show any evidence of complaints, treatment, or diagnosis for any gallbladder diseases. The Veteran was afforded a VA examination in March 2010. The Veteran reported having his gallbladder removed in 1996. Prior to the gallbladder removal, the Veteran had developed frequent heartburn and more frequent bowel movements. Since the surgery, his gallbladder has not given him any problems, but he did develop a large hernia. The examiner opined that it was less likely than not that the Veteran's residuals of a gallbladder removal were caused by or a result of a condition shown during active duty. She stated that the Veteran had verbalized some indigestion during active duty, but there is no indication of gallbladder disease or cholecystectomy. Indigestion can be attributed to a number of things including GERD and side effects of medication. The examiner noted that the Veteran served from 1966 to 1969, but the gallbladder condition did not occur until 1996. Therefore, the examiner found it was less likely as not that the gallbladder condition was a result of a condition shown during activity duty. The Veteran is competent to report the onset and duration of his indigestion. Nonetheless, medical knowledge is required in order to properly diagnose a gallbladder condition and determine the necessity to remove it. Under the circumstances, an opinion as to the precise nature and cause of the Veteran's gallbladder removal would appear to depend on clinically observed findings from examination and application of accepted medical principles. As such, the Board is inclined to assign greater probative weight to the opinion expressed by the March 2010 VA examiner than to the lay assertions contained in the record. The evidence in the record does not show that a gallbladder condition requiring the removal of the gallbladder occurred in or caused by service. The Board finds that a preponderance of the evidence is against the claim of service connection for gallbladder, and there is no doubt to be resolved. Gilbert, 1 Vet. App. at 55-57. C. GERD The Veteran contends he is entitled to service connection for residuals of gallbladder removal, to include surgical scars. As stated above, the Veteran's STRs show that on his February 1966 entrance exam, the Veteran reported pain or pressure in his chest, his heart palpitating or pounding, low blood pressure, and frequent indigestion. The Veteran reported similar symptoms on the February 1969 separation exam, citing pain or pressure in his chest, frequent indigestion, frequent or severe headaches, and dizziness or fainting spells. As for the chest pains and indigestion, the physician noted dietary issues, but no symptoms present at the time of discharge. None of the Veteran's STRs show any evidence of complaints, treatment, or diagnosis for GERD. The March 2010 VA examiner provided an addendum in April 2010. The examiner stated that indigestion is a condition that affects the release of gastric acid in the stomach and GERD is a condition in which there is incompetence of the esophageal sphincter muscle. However, she could not resolve, without mere speculation, if the Veteran's indigestion in military service was related to his current diagnosis of GERD. The Board may rely on a statement that an opinion cannot be provided without resort to "mere speculation" if it is clear that the procurable and assembled data was fully considered and the basis for the opinion is provided by the examiner and is apparent upon a review of the record. Jones, 23 Vet. App. at 389. Moreover, in this case, although the examiner's word choice referenced "speculation," the basis of this statement was that it would be speculative to find a positive nexus between the Veteran's current GERD and his time in service because there was no in-service documentation of GERD and the Veteran had years without complaints, treatment, or diagnosis of GERD. These statements were based on an accurate medical history, and the examiner's report included a thorough, detailed review of the Veteran's treatment records. While the Veteran complained of indigestion during service and currently has a diagnosis of GERD, no persuasive medical evidence shows that the current GERD is a result of a disease or condition during his military service. The Board finds that a preponderance of the evidence is against the claim of service connection for GERD, and there is no doubt to be resolved. Gilbert, 1 Vet. App. at 55-57. ORDER Service connection for a coronary artery disease is denied. Service connection for residuals of gallbladder removal, to include surgical scars, is denied. Service connection for GERD is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs