Citation Nr: 1827455 Decision Date: 05/01/18 Archive Date: 05/14/18 DOCKET NO. 15-30 526 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include major neurocognitive disorder, to include as due to Alzheimer's disease and dementia, secondary to coronary artery disease. REPRESENTATION Appellant represented by: Oklahoma Department of Veterans Affairs ATTORNEY FOR THE BOARD R. Behlen, Associate Counsel INTRODUCTION The appellant served on active duty in the Air Force from March 1956 to June 1976. He is the recipient of the Air Force Commendation Medal with one oak leaf cluster, the Air Force Good Conduct Medal with three oak leaf clusters, and the Air Force Longevity Service Award with four oak leaf clusters. This matter comes before the Board of Veterans' Appeals (Board) from an October 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The Board most recently remanded this matter in August 2017. A Supplemental Statement of the Case (SSOC) was issued in March 2018. A review of the record shows that the RO has substantially complied with all remand instructions. The appellant and his representative have not contended otherwise. Stegall v. West, 11 Vet. App. 268 (1998). The Board has recharacterized the issue on appeal as entitlement to service connection for an acquired psychiatric disorder, to include major neurocognitive disorder, to include as due to Alzheimer's disease and dementia, secondary to coronary artery disease. Given the appellant's assertions, the evidence of record, and the outcome below, no prejudice to the appellant has resulted. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993); see also Clemons v. Shinseki, 23 Vet. App. 1, 5-6, 8 (2009) (holding that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by a claimant's description of the claim, reported symptoms, and the other information of record). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). FINDING OF FACT The evidence is in equipoise as to whether the appellant's major neurocognitive disorder is causally related to his Alzheimer's disease and dementia, which are causally related to his service-connected coronary artery disease. CONCLUSION OF LAW The criteria for entitlement to service connection for major neurocognitive disorder, due to Alzheimer's disease and dementia, secondary to service-connected coronary artery disease, have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION I. Veterans Claims Assistance Act of 2000 (VCAA) Neither the appellant nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). II. Applicable Law Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. "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. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection may be established on a secondary basis for a disability that is proximately due to or the result of a 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) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. 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(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). "It is in recognition of our debt to our veterans that society has [determined that,] [b]y tradition and by statute, the benefit of the doubt belongs to the veteran." See Gilbert, 1 Vet. App. at 54. III. Analysis Service connection is in effect for coronary artery disease. The appellant has been diagnosed with Alzheimer's disease and dementia. See e.g. June 2016 letter from Dr. T.G. referencing advanced Alzheimer's dementia. It is undisputed that the appellant's currently-diagnosed major neurocognitive disorder is due to his Alzheimer's disease and dementia. See e.g. April 2015 VA examination report ("Major Neurocognitive Disorder due to Alzheimer's Disease . . . represents a continuation in the Veteran's prior diagnosis of Alzheimer's") and January 2017 VA medical opinion ("[t]he Veteran meets the criteria for the diagnosis of Major Neurocognitive Disorder due to Alzheimer's Disease"). In April 2014, following review of the appellant's medical records and medical journals, Dr. C.T. opined that it was more likely than not that the appellant's coronary artery disease is causally related to the development of his Alzheimer's disease and dementia. It was explained that coronary artery disease is also known as atherosclerotic heart disease, a form of ischemic heart disease. Atherosclerosis was noted to be a risk factor for the development of Alzheimer's disease and vascular dementia. Atherosclerosis occurs when deposits of cholesterol and plaques build up in arteries and narrow blood vessels, including in the brain. Dr. C.T. explained that because the blood flow to brain cells is reduced, such appears to increase the risk of Alzheimer's disease. The Board finds Dr. C.T.'s etiological opinion linking the appellant's service-connected coronary artery disease and his Alzheimer's disease and dementia highly probative because it was based on a review of appellant's medical history and consideration of current medical research, and the opinion was accompanied by a detailed rationale. A VA medical opinion was obtained in October 2017. The claims file was reviewed. It was noted that the appellant has been diagnosed with major neurocognitive disorder due to Alzheimer's disease. Such was noted to have also been reported as due to Alzheimer's dementia. It was explained that the appellant's problems with anxiety and depression were symptoms of such major neurocognitive disorder, rather than separately diagnosable disorders. Thus, the previous diagnoses of anxiety and depression were erroneous. The Board likewise finds the October 2017 VA medical opinion highly probative as to whether the appellant has additional acquired psychiatric disorders. The opinion was based upon a review of the claims file and is well-reasoned. The Board finds that the evidence is in relative equipoise as to whether his Alzheimer's disease and dementia are causally related to his service-connected coronary artery disease. 38 C.F.R. § 3.310(a). Likewise, the evidence is in relative equipoise as to whether the appellant's major neurocognitive disorder is causally related to his Alzheimer's disease and dementia. Id. The Court of Appeals for Veterans Claims (Court) has held that, "[t]he law does not expect the claimant to have the medical or legal expertise to file a claim requesting benefits for each technical disability in the causal chain of disabilities that composes his condition, and a claim must be read sympathetically." DeLisio v. Shinseki, 25 Vet. App. 45 (2011). In DeLisio, the Court noted that a claim for VA benefits requires "(1) an intent to apply for benefits, (2) an identification of the benefits sought, and (3) a communication in writing." Id. at 53, (citing Brokowsi v. Shinseki, 23 Vet. App. 79, 84 (2009)). Further, the Court noted that a veteran ". . . is not required in filing a claim for benefits to identify a precise medical diagnosis or the medical cause of his condition; rather, he sufficiently files a claim for benefits 'by referring to a body part or system that is disabled or by describing symptoms of the disability.'" Id., (citing Brokowski, 23. Vet. App. at 86). With respect to the October 2017 VA examiner's opinion that the appellant's previously-diagnosed anxiety and depression were not separate disorders, but rather symptoms of his major neurocognitive disorder, the only diagnosed psychiatric disorder, the Board observes that the appellant's symptoms previously attributed to anxiety and depression diagnoses are, in fact, related to his service-connected major neurocognitive disorder. Further, although the appellant originally claimed service connection for PTSD and had a private diagnosis of such, all of the VA and contracted medical opinions of record state that he does not meet the criteria for a diagnosis of PTSD. The Board finds the VA and contracted medical opinions to be of greater probative weight as to whether the appellant meets the criteria for a clinical diagnosis of PTSD, based on the clinician's greater medical knowledge. Further, such examiners attributed the appellant's reported symptoms to his major neurocognitive disorder. Thus, as with the anxiety- and depression-related symptoms, such are taken into account with his service-connected major neurocognitive disorder. Thus, the grant of service connection for major neurocognitive disorder is a full grant of the benefits sought on appeal. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6, 8 (2009) (holding that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by a claimant's description of the claim, reported symptoms, and the other information of record). As set forth above, under the benefit-of-the-doubt rule, for the appellant to prevail, there need not be a preponderance of the evidence in his favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Given the evidence set forth above, such a conclusion certainly cannot be made in this case. Under these circumstances, the record is sufficient to award service connection for major neurocognitive disorder, to include as due to Alzheimer's disease and dementia, secondary to service-connected coronary artery disease. ORDER Entitlement to service connection for major neurocognitive disorder, to include as due to Alzheimer's disease and dementia, secondary to service-connected coronary artery disease, is granted, subject to the law and regulations governing the payment of monetary benefits. ______________________________________________ DAVID GRATZ Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs