Citation Nr: 18152241 Decision Date: 11/21/18 Archive Date: 11/21/18 DOCKET NO. 17-45 946 DATE: November 21, 2018 ORDER Entitlement to service connection for gastroesophageal reflux disease (GERD) is denied. REMANDED Entitlement to service connection for coronary artery disease (CAD) is remanded. Entitlement to service connection for a right knee disorder, to include arthritis, is remanded. FINDING OF FACT The preponderance of the evidence is against finding that GERD began during active service, or is otherwise related to an in-service injury, event, or disease. CONCLUSION OF LAW The criteria for service connection for GERD are not met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Navy from July 1969 to July 1989. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially 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). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert. v. Derwinski, 1 Vet. App. 49, 55 (1990). 1. Entitlement to service connection for GERD. On the June 2016 notice of disagreement (NOD), the Veteran stated that his in-service chest pain may have been the result of GERD that went undiagnosed until after separation from service. The service treatment records (STRs) are silent of any complaint of or treatment for GERD. The first post-service indication of GERD was in a January 2003 private treatment record. The Veteran was discharged from the hospital for surgery and the medical provider indicated that the Veteran had a diagnosis of GERD. On the May 2017 VA examination, the examiner indicated that the Veteran was diagnosed with GERD in 2005. The examiner opined that the Veteran’s GERD was less likely than not incurred in or caused by service. The examiner reasoned that there were no in-service reports of GERD. The examiner acknowledged that the Veteran reported experiencing costochondritis (chest pain) in 1972, but the costochondritis was not due to GERD. The examiner stated that the etiology of GERD may never fully be known and there is limited medial documentation from service, aside from the separation physical. Based on the foregoing, there is no evidence that the Veteran’s GERD was manifested in service or to a compensable degree in the first year following his separation from service. Consequently, service connection for GERD on the basis that such became manifest in service and persisted is not warranted. Notably, the Veteran has not submitted competent evidence to show that he has suffered from GERD continuously since service. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). There is also no evidence that the Veteran’s GERD is otherwise related to service. The Veteran’s post-service private treatment records are silent for an opinion relating his GERD to service. The only competent evidence in the record that addresses this question is the May 2017 VA medical opinion, which stated that the Veteran’s GERD was not related to his service. As there is no other evidence to the contrary, the May 2017 VA medical opinion was based on a full review of the record as well as an interview and examination of the Veteran, the Board finds it persuasive. Further, the Veteran’s own statements relating his GERD to service are not competent evidence, as he is a layperson and lacks the training to provide adequate opinion regarding medical etiology. Specifically, the Veteran lacks the training to opine whether GERD, in the absence of credible evidence of continuity, as here, is related to in-service costochondritis. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (Whether lay evidence is competent and sufficient in a particular case is a fact issue to be addressed by the Board rather than a legal issue to be addressed by the U.S. Court of Appeals for Veterans Claims). Also, GERD is a disease of the digestive system, and the record does not show that the Veteran has training or education in this medical field; therefore, lay evidence of the etiology is not competent nexus evidence. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007); Layno v. Brown, 6 Vet. App. 465, 469-70. Thus, the Veteran is not competent or qualified, as a layperson, to render an opinion on medical causation. In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran’s claim to service connection for GERD. Accordingly, it must be denied. REASONS FOR REMAND 1. Entitlement to service connection for CAD. The Board is not free to substitute its own judgment for that of an expert. Colvin v. Derwinski, 1 Vet. App. 171 (1991). The Veteran asserts that his in-service chest pain and bradycardia caused is CAD. Here, the April 2016 VA examiner opined that the Veteran’s CAD was less likely than not incurred in or caused by service. The examiner reasoned that the Veteran’s STRs do not show a diagnosis of heart disease or CAD. Further, the examiner stated that athletes that are well conditioned can have a normal sinus rhythm with a slow rate considered bradycardia and the Veteran’s bradycardia finding is not equivalent to CAD or ischemic heart disease (IHD). Also, the Veteran had an in-service incident of chest wall pain, however, chest wall pain does not represent CAD or IHD. In an August 2016 private treatment letter, the private provider stated that the Veteran had significant bradycardia that developed intermittent pauses. She stated that this was not the result of exercise and as a result the Veteran required a pacemaker implant for treatment of this issue. As the examiner did not have available for consideration the August 2016 finding of the private treatment provider, the examination is inadequate. Therefore, the Board remands this matter for an addendum opinion as to the etiology of the Veteran’s current CAD, with consideration of the submitted private treatment letter. 2. Entitlement to service connection for a right knee disorder, to include arthritis, is remanded. Remand is necessary to obtain an addendum opinion, or a new VA examination if deemed necessary. When VA undertakes to obtain an opinion, it must ensure that the opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is considered adequate “where it is based on consideration of the veteran’s prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board’s evaluation of the claimed disability will be a fully informed one.” Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Here, the April 2016 VA examiner opined that the Veteran’s right knee disorder was less likely than not proximately due to or the result of the Veteran’s service connected left knee disorder. The examiner reasoned that the Veteran’s left knee disorder was resolved in-service because of surgery, therefore the previous left knee condition is less likely as not the cause of the Veteran’s current right knee disorder. However, the examiner did not offer an opinion regarding the Veteran’s in-service complaints of bilateral knee pain, achiness, and stiffness. Further, the examiner did not address the February 1979 examination finding that the Veteran had arthritis of the bilateral knees. Therefore, a remand is required to obtain an addendum opinion, or VA examination if deemed necessary, to determine the etiology of the Veteran’s right knee disorder. The matter is REMANDED for the following action: 1. Obtain an addendum opinion for CAD from an appropriate medical professional, or a new VA examination if deemed necessary, to consider the August 2016 private treatment letter submitted by the Veteran and address the private treatment provider’s finding in the addendum opinion. The examiner must opine whether the Veteran’s CAD is at least as likely as not related to service, to include multiple in-service complaints of chest pain and any findings of bradycardia. 2. Obtain an addendum opinion for a right knee disorder from an appropriate medical professional, or a new VA examination if deemed necessary, to consider the STRs report of arthritis and bilateral knee pain, aching, and stiffness. The examiner must opine whether any right knee disorder, to include arthritis, is at least as likely as not directly related to service, to include the Veteran’s in-service complaints of knee pain, aching, and stiffness; June 1971 findings of crepitus and tenderness of the patellae; and the February 1979 examination indicating that the Veteran had arthritis of the knees. The examiner must also opine as to whether it is at least as likely as not that: • The Veteran’s right knee disorder was caused or aggravated by the service-connected left knee disorder; and • If the Veteran’s right knee disorder was aggravated, was the aggravation beyond the natural progression of the disability. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans’ Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C. §§ 5109B, 7112 (2012). K.A. KENNERLY Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Thompson, Associate Counsel