Citation Nr: 18143107 Decision Date: 10/18/18 Archive Date: 10/17/18 DOCKET NO. 16-03 831 DATE: October 18, 2018 ORDER Service connection for ischemic heart disease is denied. Service connection for diabetes mellitus, type II, is denied. Service connection for posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to service connection for psoriasis is remanded. Entitlement to service connection for psoriatic arthritis is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of ischemic heart disease. 2. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of diabetes mellitus, type II. 3. Resolving reasonable doubt in the Veteran’s favor, his PTSD is at least as likely as not related to an in-service stressor. CONCLUSIONS OF LAW 1. The criteria for service connection for ischemic heart disease are not met. 38 U.S.C. §§ 1110, 1112, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). 2. The criteria for service connection for diabetes mellitus, type II, are not met. 38 U.S.C. §§ 1110, 1112, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). 3. The criteria for service connection for posttraumatic stress disorder are met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304(f) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran honorably served on active duty from November 1968 to December 1970. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an August 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. The Board is grateful for the Veteran’s honorable and meritorious service to this country. Duties to Notify and Assist With respect to the claim decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Service Connection for Ischemic Heart Disease and Diabetes Mellitus Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Service connection requires evidence showing: (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a causal link (“nexus”) between the current disability and the disease or injury incurred or aggravated in service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). In certain circumstances, VA recognizes that specific diseases are associated with exposure to herbicide agents and, therefore, evidence of the nexus or causal link will be presumed, unless there is affirmative evidence to establish that the disease is due to an intercurrent injury or disease. 38 U.S.C. § 1116 (a); 38 C.F.R. §§ 3.307 (a)(6), 3.307(d)(1), 3.309(e). In the absence of a current disability, service connection cannot be granted for such disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or at any time during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 319 (2007). When there is an approximate balance of positive and negative evidence regarding the merits of an issue, the benefit of the doubt must be given to the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. If the preponderance of the evidence is against the issue, the issue is to be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). I. Ischemic Heart Disease With his informal claim for service connection for ischemic heart disease, the Veteran submitted an examination report and opinion prepared by a chiropractor. See June 2013 Report of Consultation and Examination by P.Y., D.C. In this report, the chiropractor provided a provisional diagnosis of ischemic heart disease, with a recommendation that a cardiologist confirm the diagnosis. Id. The Board finds that this diagnosis cannot be assigned significant probative value because it was not later confirmed and there is no indication that this chiropractor is qualified (“competent”) to provide a cardiac diagnosis. A medical doctor performed a cardiac evaluation of the Veteran and opined that the Veteran does not have and has not ever been diagnosed with a heart condition. See July 2014 VA Examination by I.V., M.D. The examination report includes the examiner’s note that the Veteran reported that he had not requested service connection for heart disease, has no cardiac symptoms at any level of physical activity, and denies anginal symptoms, such as chest pain, shortness of breath, dizziness or exertion. Id. The Board finds that this report has significant probative value because a medical doctor is qualified to conduct cardiac examinations and provide opinions on cardiac functioning. Service connection is limited to those cases where disease or injury has resulted in a disability. In the absence of proof of a current disability for which service connection is sought, there is no valid claim of service connection. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). Accordingly, because the preponderance of the evidence is against a finding that the Veteran has had a cardiac condition at any time during the course of this appeal, the claim for service connection for ischemic heart disease must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.303; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). II. Diabetes Mellitus, Type II With his informal claim for service connection for diabetes mellitus, the Veteran submitted an examination report and opinion prepared by a chiropractor. See June 2013 Report of Consultation and Examination by P.Y., D.C. In this report, the chiropractor provided a diagnosis of type II diabetes based on a single blood glucose reading, which the chiropractor noted was to be “followed up with a confirmatory hemoglobin A1C.” Id. The Board finds that this diagnosis cannot be assigned significant probative value because there was no later A1C test to confirm the diagnosis and there is no indication that this chiropractor is qualified to provide a endocrinological diagnosis. A medical doctor performed a diabetes evaluation of the Veteran and opined that the Veteran does not have a diabetic condition. See July 2014 VA Examination by I.V., M.D. The report includes glucose testing and A1C results. Id. Based on the examination and review of the records, including the chiropractic report, the examiner opined that the Veteran “does not meet the criteria for diagnosis of [diabetes mellitus] or impaired fasting glucose on today’s labs.” Id. The Board finds that this report has significant probative value because a medical doctor is qualified to conduct diabetic evaluations and provide opinions on diabetic functioning. As noted above, service connection is limited to those cases where disease or injury has resulted in a disability. In the absence of proof of a current disability for which service connection is sought, there is no valid claim of service connection. See Brammer, 3 Vet. App. at 223. Accordingly, because the preponderance of the evidence is against a finding that the Veteran has had a diabetic condition at any time during the course of this appeal, the claim for service connection for diabetes mellitus, type II, must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.303; Gilbert, 1 Vet. App. at 55. Service Connection for Posttraumatic Stress Disorder (PTSD) Service connection for PTSD is subject to slightly different requirements than the disabilities above. Service connection for PTSD may be established if it results from an in-service stressor. 38 U.S.C. § 1131; 38 C.F.R. § 3.304(f). Establishing service connection for PTSD requires evidence showing: (1) a current diagnosis of PTSD consistent with 38 C.F.R. §4.125(a); (2) credible supporting evidence that the claimed in-service stressor occurred; and (3) medical evidence of a causal link (“nexus”) between the current symptoms and an in-service stressor. See 38 C.F.R. § 3.304(f). When there is an approximate balance of positive and negative evidence regarding the merits of an issue, the benefit of the doubt must be given to the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. If the preponderance of the evidence is against the issue, the issue is to be denied. Gilbert, 1 Vet. App. at 55. I. PTSD Stressor The threshold issue is whether the Veteran has a legally sufficient diagnosis of PTSD. However, this depends in part on the form of the Veteran’s stressor. If the stressor is “fear of hostile military or terrorist activity,” the Veteran is required to have a VA psychiatrist or psychologist confirm that the Veteran’s stressor is adequate to support a PTSD diagnosis and that the symptoms are related to the claimed stressor. See 38 C.F.R. § 3.304(f)(3). In this case, the Board finds that this requirement is not applicable because the Veteran’s stressor is related to engaging in combat as described in 38 C.F.R. § 3.304(f)(2). The Veteran has identified stressors related to his work piloting helicopters on combat assault missions while serving in the Republic of Vietnam. See June 2013 Psychological Evaluation by W.A., Psy.D.; July 2014 VA Examination by J.M., Psychologist. In particular, the Veteran provided evidence of a newspaper article published by his brigade that reported that he was fired upon by enemy soldiers in the course of a mission, in which he had to go back down to the site of combat to re-deposit soldiers to defend against the attack. See June 2013 Veteran’s Submitted Supporting Evidence. Sustaining enemy fire and engaging in actions to assist with the active defense of ones’ craft is a quintessential example of what it means to be engaged in combat with the enemy. See Sizemore v. Principi, 18 Vet. App. 264, 272-273; see also VAOPGCPREC 12-99 (noting that “incurred in combat” has historically included injury caused by an instrumentality of war while being “engaged in attacking, defending, or sustaining an attack of the enemy”) (emphasis added). Although the Veteran’s submitted awards are for “meritorious service,” and do not independently confirm combat engagement, see September 2014 Veteran’s Submitted Awards, their existence in combination with the Veteran’s submitted newspaper article provide credible and probative evidence that the Veteran was in fact engaged in combat. II. Diagnosis of PTSD under 4.125(a) Turning to whether the Veteran has a valid diagnosis of PTSD under 38 C.F.R. § 4.125(a), the Board find that he does have a legally sufficient diagnosis of PTSD. Notably, based on when the Veteran filed his claim, the regulations require that his diagnosis conform to either the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) or the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). See 38 C.F.R. § 4.125 (2017); 80 Fed. Reg. 14, 308 (March 19, 2015). In this case, the Veteran has a diagnosis from a private psychological examiner under the DSM-IV. See June 2013 Psychological Evaluation by W.A., Psy.D. (comparing the list of symptoms required for diagnosis under DSM-IV with the Veteran’s symptoms). In contrast, a VA examiner opined that the Veteran met neither of the diagnostic requirements of the DSM-5 or DSM-IV. See July 2014 VA Examination by J.M., Psychologist. The RO attempted to reconcile this difference by obtaining an addendum opinion, but this third examiner indicated that he could not account for the discrepancy without resorting to speculation. See August 2014 VA Addendum Opinion by Z.T., Ph.D. Accordingly, the evidence is at least evenly balanced for and against (“in relative equipoise”) a finding that the Veteran has a current disability of PTSD. III. Medical Link (“Nexus”) Having established that the Veteran has an in-service stressor and a legally sufficient diagnosis of PTSD, the sole remaining issue is whether there is a causal link (a “nexus”) between the two. See 38 C.F.R. § 3.304(f). In this regard, there is only one medical opinion that provides qualified evidence on the matter. The Veteran’s private psychological examiner reported that the Veteran’s symptoms are as likely as not service-connected. Although there is little explanation for how he came to this conclusion, it is clear from reading the opinion as a whole that this conclusion was based on a clinical interview with the Veteran and review of the Veteran’s stressor evidence, discussed above. June 2013 Psychological Evaluation by W.A., Psy.D.; see Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (VA examination report “must be read as a whole” to determine the examiner’s rationale); see also Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (“[T]here is no reasons or bases requirement imposed on [medical] examiners.”). Accordingly, the Board finds this evidence probative on the matter. The competent and credible evidence supports a current diagnosis of PTSD linked to the Veteran’s stressor of being engaged in combat with the enemy. Accordingly, the Board finds that the preponderance of the evidence supports the claim and service connection for PTSD is granted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.303; Gilbert, 1 Vet. App. at 55. REASONS FOR REMAND Entitlement to service connection for psoriasis and psoriatic arthritis is remanded. With the Veteran’s informal claims of service connection for psoriasis and psoriatic arthritis, he submitted a chiropractor’s examination and opinion. See June 2013 Report of Consultation and Examination by P.Y., D.C. In this report, the chiropractor provided a diagnosis of psoriasis and noted that the Veteran reported in-service symptoms of exfoliative lesions, which have persisted since this time. Although there is no evidence that the Veteran’s chiropractor is qualified to diagnose psoriasis or psoriatic arthritis, the Veteran himself is qualified to provide lay evidence of his symptoms, including when they began, and how long they have persisted. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). VA is required to provide an examination when there is insufficient medical evidence to decide the claim, but the record otherwise contains competent evidence of a current disability or recurrent symptoms, evidence of an in-service event, and an “indication” that there is a causal link between the in-service symptoms or event and the current diagnosis. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); 38 C.F.R. § 3.159(c)(4)(i). Psoriatic arthritis is a “syndrome of psoriasis in association with inflammatory arthritis.” See DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 139 (Saunders 30th ed. 2003). Therefore, this matter is inextricably intertwined with the issue of service connection for psoriasis; accordingly, it must be remanded as well. The matters are REMANDED for the following action: 1. Obtain a VA examination of the Veteran to determine the nature and likely cause of the Veteran’s claimed psoriasis. The examiner should review the claim file (including this remand) and note that the review was conducted. Based on review of the record and an examination of the Veteran, the examiner should provide an opinion with a detailed explanation (rationale) regarding whether it is at least as likely as not (50 percent or greater probability) that psoriasis was either incurred in or otherwise related to Veteran’s military service. It is emphasized that the Veteran is qualified to report what his symptoms are, when they began, and how long they have persisted. If the Veteran’s statements are inconsistent with the medical evidence, the examiner must provide a comprehensive report including a complete explanation (rationale) for all opinions and conclusions reached, citing the objective medical findings or other evidence leading to the conclusion that his statements are inconsistent with the medical evidence. Detailed rationale and reasoning for all opinions and conclusions provided is required BY LAW. Providing an opinion without a thorough explanation will delay processing of the claim and may result in a clarification being requested. If it is not possible to provide any of the requested information, the examiner must state whether this is because of a deficiency in the state of general medical knowledge (that is, no one could respond, given medical science and the known facts), a deficiency in the record (that is, additional facts are required), or the examiner (that is, the examiner does not have the required knowledge or training). If the examiner cannot provide answers because further information or diagnostic studies are required, all reasonable steps to obtain this information or diagnostic studies should be exhausted before concluding that the answer cannot be provided. 2. After completing the prior directive, obtain a VA examination of the Veteran to determine the nature and likely cause of the Veteran’s claimed psoriatic arthritis. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale regarding whether it is at least as likely as not (50 percent or greater probability) that psoriatic arthritis was either incurred in or otherwise related to Veteran’s military service. It is emphasized that the Veteran is qualified to report what his symptoms are, when they began, and how long they have persisted. If the Veteran’s statements are inconsistent with the medical evidence, the examiner must provide a comprehensive report including a complete explanation (rationale) for all opinions and conclusions reached, citing the objective medical findings or other evidence leading to the conclusion that his statements are inconsistent with the medical evidence. Detailed rationale and reasoning for all opinions and conclusions provided is required BY LAW. Providing an opinion without a thorough explanation will delay processing of the claim and may result in a clarification being requested. If it is not possible to provide any of the requested information, the examiner must state whether this is because of a deficiency in the state of general medical knowledge (that is, no one could respond, given medical science and the known facts), a deficiency in the record (that is, additional facts are required), or the examiner (that is, the examiner does not have the required knowledge or training). [CONTINUED ON THE NEXT PAGE] If the examiner cannot provide answers because further information or diagnostic studies are required, all reasonable steps to obtain this information or diagnostic studies should be exhausted before concluding that the answer cannot be provided. VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Lambert, Associate Counsel