Citation Nr: 20003074 Decision Date: 01/14/20 Archive Date: 01/14/20 DOCKET NO. 16-30 050 DATE: January 14, 2020 ORDER Entitlement to service connection for migraine headaches is granted. Entitlement to service connection for idiopathic cardiomyopathy with left ventricular dysfunction, congestive heart failure and atrial fibrillation is denied. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran’s favor, her migraine headaches condition is proximately due to her service-connected posttraumatic stress disorder (PTSD). 2. The preponderance of the evidence is against finding that the Veteran’s idiopathic cardiomyopathy with left ventricular dysfunction, congestive heart failure and atrial fibrillation began during active service, or is otherwise related to an in-service injury or disease, to include as secondary to the Veteran’s service-connected PTSD disability. CONCLUSIONS OF LAW 1. The criteria for service connection for the Veteran’s claimed for migraine headaches condition are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for idiopathic cardiomyopathy with left ventricular dysfunction, congestive heart failure and atrial fibrillation due to service, to include as secondary to the Veteran’s service-connected PTSD, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from August 1965 to August 1967. This matter comes before the Board of Veterans’ Appeals (Board) from October 2013 and May 2014 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that a hearing was held in May 2019 before the undersigned Veterans Law Judge. A transcript of that hearing is of record. At the outset, the Board notes that the Veteran has waived AOJ consideration of the medical evidence submitted in support of her claim in May and June of 2019. See June 2019 Statement in Support of Claim; June 2019 Medical Nexus Opinion by Dr. S. B-J; May 2019 Statement in Support of Claim; October 2016 private treatment record by Dr. W.H.L. 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, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). In order to prevail under a theory of secondary service connection, there must be: (1) evidence of a current disorder; (2) evidence of a service-connected disability; and, (3) medical nexus evidence establishing a connection between the service-connected disability and the current disorder. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Board notes here that the Veteran contends, as alternative theories of entitlement, that her claimed for conditions are secondary to her service-connected PTSD condition. 1. Entitlement to service connection for migraine headaches The question before the Board is whether the Veteran’s claimed for migraine headaches condition is at least as likely as not related to an in-service injury, event, or disease, to include as secondary to the Veteran’s service-connected PTSD. As the Board is granting the Veteran’s claim for service connection on a secondary basis theory of entitlement, direct service connection will not be addressed herein. For secondary service connection, the Veteran must show a current disability. Per the Veteran’s September 2013 VA examination, she was diagnosed with migraine headaches in 1968, as well as tension headaches in 1966. Thus, the Board finds that the Veteran’s claim meets the first element of secondary service connection. As to the second element of secondary service connection, the Veteran must show evidence of a service-connected disability. Per an October 2013 Rating Decision, the Veteran’s claimed for PTSD condition was service connected by the RO. Thus, as the Veteran is claiming that her condition of migraine headaches is secondary to PTSD, a disability for which is she service-connected, the Board finds that the Veteran’s claim meets the second element of secondary service connection. As to the last element of secondary service connection, the Veteran must show medical nexus evidence establishing a connection between the service-connected disability and the claimed for condition. On the issue of nexus, there are no medical opinions weighing against the Veteran’s claim relative to her secondary service connection theory of entitlement. There is, however, a June 2019 positive medical nexus opinion from a VA staff physician, Dr. S.B-J, whom opined that the Veteran’s migraine headaches condition is at least as likely as not related to her service-connected PTSD. Dr. S.B-J remarked that the Veteran is followed in multiple clinics in the VA HCS. While the opinion does not include a specific rationale, it was provided by a competent medical professional who apparently has familiarity with the Veteran and the Board finds that his opinion is credible and probative. The pertinent medical evidence of record reveals that the Veteran’s migraine headaches condition is well documented with numerous instances when she sought treatment for the condition. See VA and private treatment records. The Board notes one specific August 2015 VA treatment record that diagnosed the Veteran with a sudden severe headache, but with no known cause. Thus, other than the medical nexus opinion from Dr. S.B-J linking her condition to her service-connected PTSD, the record does not support any other known etiology for the Veteran’s claimed for migraine headaches condition. To point, the September 2013 VA medical examiner found that the current migraine headache condition was less likely incurred in or caused by cephalgia, diagnosed as tension headache that occurred throughout service as migraine headache diagnosed after service is another classification of headache. The examiner suggested that her migraines may be of a genetic nature, as her mother was also diagnosed with the condition, but that migraines are also known to be caused by environmental factors as well. The examiner did not address the relationship between the current migraine headaches and the service-connected PTSD and is not probative with regard to secondary service connection. The Board acknowledges the Veteran’s lay testimony relating her migraine headaches condition to her service-connected PTSD disability. See May 2019 Board hearing transcript. While the Veteran is competent to describe her migraine headache symptoms, as the cause of any neurological disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and effect relationship, she is not competent to render a complex medical opinion regarding the etiology of her migraine headache condition. As such, the question of etiology in this case may not be competently addressed by lay evidence. See Layno v. Brown, 6 Vet. App. 465, 469 - 470 (1994); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Upon review, the Board finds that the pertinent evidence of record to be at least in equipoise as to whether the Veteran’s current migraine headaches condition is related to her service-connected PTSD disability. The Veteran has a current migraine headaches condition, she is service-connected for PTSD, and there is medical evidence of record that definitively links the two conditions. Accordingly, after resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for the claimed for condition of migraine headaches, as secondary to the Veteran’s service-connected PTSD, is warranted. 38 C.F.R. § 3.310(a). The claim is granted. 2. Entitlement to service connection for idiopathic cardiomyopathy with left ventricular dysfunction, congestive heart failure and atrial fibrillation The question before the Board is whether the Veteran’s claimed for idiopathic cardiomyopathy with left ventricular dysfunction, congestive heart failure and atrial fibrillation condition is at least as likely as not related to an in-service injury, event, or disease, to include as secondary to the Veteran’s service-connected PTSD. As to the Veteran’s direct theory of entitlement, for service connection she must show a current disability. Per the Veteran’s VA treatment records, she currently has a diagnosis for Cardiomyopathy. Thus, the Board finds that the Veteran’s claim for service connection meets the first Shedden element of service connection. As the second element for direct service connection, the Veteran must show an in-service incurrence or aggravation of a disease or injury. Here, the Board notes that the Veteran’s service treatment records are negative for any complaints, treatment, or diagnosis relating specifically to the claimed for condition. To point, the Veteran testified before the undersigned VLJ that she was not treated for the condition until 1974. See May 2019 Board hearing transcript. Additionally, the Board finds that on the issue of nexus, there are no probative medical opinions of record that link the claimed for condition to service under a direct service connection theory of entitlement. Therefore, as the preponderance of the evidence weighs against the Veteran’s claim for service connection on a direct theory of entitlement, the benefit of doubt doctrine is not for application, and entitlement to service connection is not warranted. As to the Veteran’s secondary service connection theory of entitlement, she claims that her condition is secondary to PTSD. As previously determined, the Veteran has a current diagnosis for the claimed for condition and is also service-connected for PTSD. Thus, the Board finds that the Veteran’s claim meets the first two elements for secondary service connection. As to the last element of secondary service connection, the Veteran must show a medical nexus evidence establishing a connection between the service-connected disability and the current disorder. The Board notes that there are no probative medical opinions that specifically link the Veteran’s claimed condition to her service-connected PTSD disability. The Veteran did submit an October 2016 private treatment record by Dr. W.H.L. that stated the Veteran’s claimed condition may possibly be related to PTSD. However, this statement does not provide, but rather merely suggests, that the Veteran’s condition may be related to her service-connected PTSD disability. Id. To the contrary, the most probative medical evidence of record, that which considered the medical literature submitted by the Veteran in support of her claim, provided that the Veteran’s claimed for condition is less likely than not (less than 50 percent) proximately due to or the result of her service-connected PTSD. See June 2017 VA addendum medical opinion. The rationale being that the etiology of the claimed for condition remains unknown, and the medical literature submitted by the Veteran does not conclusively establish that her service-connected PTSD was the cause of her claimed for condition. Id. Here, the Board notes that the VA examiner reviewed Veteran’s claims file, to include the April 2014 VA medical opinion addressing the same issue, the Veteran’s VBMS file, as well as the medical literature submitted by the Veteran in support of her claim. Id. The Board acknowledges the Veteran’s lay testimony in support of her theories of entitlement to service connection for the claimed for condition; however, the Board notes that the condition of idiopathic cardiomyopathy with left ventricular dysfunction, congestive heart failure and atrial fibrillation is medically complex in nature and the evidence of record does not support a showing that the Veteran possesses the requisite medical expertise or knowledge to opine as to that condition’s etiology and whether it is related to active duty service, to include by way of being medically linked to a service-connected disability. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). Ultimately the Board finds that the preponderance of the evidence is against the Veteran’s claim for secondary service connection, as there are no probative medical opinions of record that link the Veteran’s currently diagnosed idiopathic cardiomyopathy with left ventricular dysfunction, congestive heart failure and atrial fibrillation condition to the Veteran’s service-connected PTSD disability. Therefore, secondary service connection is not warranted, and the claim must be denied. The Board considered the benefit of the doubt doctrine, but as the preponderance of the evidence weighs against the Veteran’s secondary service connection theory of entitlement, the doctrine is not for application. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S.R. Fey, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.