Citation Nr: 18158785 Decision Date: 12/17/18 Archive Date: 12/17/18 DOCKET NO. 15-30 391 DATE: December 17, 2018 ORDER Entitlement to service connection for gastritis and gastroesophageal reflux disease (GERD), is granted. Entitlement to service connection for boils and/or abscesses with residual scarring is granted. FINDINGS OF FACT 1. The Veteran’s gastritis and GERD (gastrointestinal disability) were temporarily aggravated beyond their natural progression by the medications he took to treat his service-connected hepatitis C. 2. The boils and/or abscesses (skin condition) experienced by the Veteran during the period on appeal was proximately caused by the medication he took to treat his service-connected hepatitis C, and resulted in residual scarring. CONCLUSIONS OF LAW 1. The criteria for service connection for a gastritis and GERD are met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310(a), (b). 2. The criteria for service connection for boils and/or abscesses with residual scarring are met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310(a), (b). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from July 1972 to July 1975 and from October 1975 to October 1978. The Board thanks the Veteran for his service. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an December 2012 rating decision (denying entitlement to service connection for gastroesophageal reflux disease (GERD) and boils) and a July 2013 rating decision (denying service connection for gastritis). The Board notes that, although the Department of Veterans Affairs (VA) Regional Office (RO) issued separate rating decisions for gastritis and GERD, the Veteran has generally considered these conditions to be the same. Indeed, although the Veteran’s January 2013 Notice of Disagreement (NOD) only appealed the RO’s determination as to his boils, in April 2013 the Veteran submitted a claim form to “reopen” his claim for “GERD/gastritis.” When a claimant asserts service connection, he does so for symptoms regardless of how those symptoms are diagnosed or labeled. See Brokowski v. Shinseki, 23 Vet. App. 79 (2009) (holding that a claimant may satisfy the requirement to identify the benefit sought by referring to a body part or system that is disabled or by describing symptoms of the disability); see also Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). As such, the Board has recharacterized the issues on appeal as listed on the title page. Because the Veteran timely submitted an NOD for his gastrointestinal disability in December 2013, the matter is properly before the Board for both conditions. In September 2018, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. Service Connection Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a Veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id. 1. Entitlement to service connection for a gastrointestinal disability The Veteran contends that his gastrointestinal disabilities, to include GERD and gastritis, were aggravated by the treatment he underwent for his service-connected hepatitis C. Notations in the medical record from February 2011 and May 2012 state that the Veteran has current diagnoses from at least August 2010, to include GERD and gastritis. These diagnoses are confirmed in VA examinations dated November 2012 and May 2013, as well as by the Physician Assistant (PA) who most recently treated the Veteran’s service-connected hepatitis C. Notation from a November 2012 medical appointment indicates that the Veteran was “seen in urgent care for his severe GERD” at some point between July and November 2012. In an April 2013 letter, the Veteran’s treating PA stated that he received treatment for hepatitis C from January 2012 to February 2013. The letter states that the Veteran’s gastrointestinal conditions were aggravated by his hepatitis C treatment, and that it was “likely secondary to” the hepatitic C medications because “gastric upset, nausea problems are a known side effect of the hepatitis C medications.” Nothing in the record contradicts the PA’s findings, and medical literature submitted showing the known side effects of one of the medications taken by the Veteran confirms that the medication is known to cause nausea, vomiting, dyspepsia, abdominal pain, and peptic ulcer. The Board acknowledges that there are negative VA examinations of record regarding whether the hepatitis C medications used to treat the Veteran may have aggravated his gastrointestinal disabilities. Specifically, examiners opined in May 2013 (for GERD) and June 2013 (for gastritis) that the conditions were less likely than not permanently aggravated by the hepatitic C treatment. However, it is not necessary for a condition to be permanently aggravated for a veteran to be entitled to secondary service connection. Because the wrong standard was applied, that portion of the examinations is given no probative value. The examinations do actually support a finding that the Veteran’s gastrointestinal conditions were aggravated by his hepatitis C treatment based on their remaining language. In the May 2013 examination, the examiner stated that “it is clear that the veteran’s pre-existing GERD condition was exacerbated during the time of treatment for SC hep c condition.” The examiner also conceded in the June 2013 opinion that Veteran’s gastritis was temporarily aggravated during his hepatitis C treatment. The Board has noted that under the current version of 38 C.F.R. § 3.310, the baseline severity of the disorder prior to the grant of service connection must be determined. If the medical evidence is adequately developed, the baseline degree of aggravation should be attainable. See 71 Fed. Reg. 52,744. Based on the foregoing, the Board finds that the Veteran’s gastrointestinal conditions have been aggravated beyond their natural progression by the medications taken for his service-connected hepatitis C. Accordingly, service connection is warranted on a secondary basis due to aggravation. 2. Entitlement to service connection for a skin condition (claimed as boils) The Veteran contends that his skin condition (claimed as boils) was proximately caused by the treatment he underwent for his service-connected hepatitis C. Medical records show that the Veteran first sought treatment for a skin condition, alternately described as boils or abscesses, in March 2012, at which time they were present on his left axilla (underarm) and the tip of his nose. The Veteran sought treatment four additional times for the condition in May, September, and November of that year. Records show that the boils generally developed in one or both underarm areas. At his hearing, the Veteran stated that he had never had boils before starting his hepatitic C medications, and that the condition was worse in his left underarm than in his right underarm. A notation from May 2013 states that the Veteran had no more boils since discontinuing interferon treatment. A January 2013 letter from the Veteran’s treating PA states that it is “very likely” that the abscesses the Veteran experienced were due to the medications the Veteran was taking for his hepatitic C. The PA’s rationale was that all three medications can cause rashes, ribavirin can cause dermatitis, and “peginterferon administration can increase a person’s inclination for infection.” Additionally, the “extended duration of treatment (greater than a year),” combined with the known side effects, made the medications likely to be responsible for the abscesses the Veteran was experiencing. The same medical literature referenced above confirms that ribavirin can cause dermatologic side effects and may cause autoimmune/infection disorders when used in combination therapy. One negative VA examination is of record from November 2012. The examiner stated that the Veteran’s boils are less likely than not related to his hepatitic C or its treatment by interferon because (1) boils are a bacterial infection and hepatitis C is a viral infection, so “causality is nonexistent” between the two conditions, and (2) “there is no established data to support that boils [furuncles] are due to hepatitis C or its treatment of interferon.” The Board finds that the rationale in the January 2013 letter from the PA is more persuasive in the instant case than is the rationale from the November 2012 VA examination because it is based on the Veteran’s actual medical record, full consideration of the facts, and a more complete discussion of potential side effects of all relevant medications. Specifically, the November 2012 examination failed to acknowledge that the Veteran was on a combination therapy of three medications and, although it acknowledged that interferon is associated with some “dermatologic manifestations,” it dismissed outright (without discussion) that those known side effects could be pertinent. Additionally, the Board notes that the PA’s rationale is supported by the timeline of the Veteran’s skin condition, which began in March 2012 (two months after hepatitis C treatment began) and stopped by May 2013 (soon after treatment stopped in February 2013). The Board notes that the Veteran experienced scarring from the boils or abscesses, which were lanced and drained for treatment. Two medical appointments from November 2012 note that the Veteran experienced hyperpigmentation on his skin “from old abscesses and lances.” The spots were treated with steroid cream. A November 2012 VA examination stated that the VA had non-painful, stable, superficial scars to his left and right axilla from incision and drainage of the boils. At his September 2018 hearing, the Veteran asserted that his scars are painful and tender. Based on the foregoing, the Board finds that the Veteran’s skin condition, manifested by boils or abscesses, was at least as likely as not proximately caused by the treatment for the Veteran’s service-connected hepatitis C. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Anderson, Associate Counsel