Citation Nr: 20027554 Decision Date: 04/20/20 Archive Date: 04/20/20 DOCKET NO. 18-51 373 DATE: April 20, 2020 ORDER As new and material evidence has been received, the service connection claim for anemia is reopened. As new and material evidence has been received, the service connection claim for chronic pain syndrome is reopened. An effective date of October 21, 2013, but no earlier, for the 50 percent rating for the service-connected headache disability is granted. Service connection for anemia, as secondary to the service-connected uterine fibroids and menorrhagia, is granted. Service connection for chronic abdominal pain, as a residual of the service-connected gallbladder and three hernia repair surgeries, is granted. Service connection for an acquired psychiatric disability, as secondary to the service-connected gallbladder and hernia surgeries, is granted. FINDINGS OF FACT 1. An unappealed July 2009 rating decision, of which the Veteran was notified of in August 2009, denied service connection for anemia. The Veteran did not submit a timely notice of disagreement to the rating decision and additional relevant evidence was not received within one year of the notice of the rating decision. 2. New evidence received since the final July 2009 final rating decision raises a reasonable possibility of substantiating the service connection claim for anemia disability. 3. An unappealed September 2009 rating decision denied service connection for chronic pain syndrome. The Veteran submitted a timely notice of disagreement but did not perfect her appeal to the Board. Thus, the September 2009 rating decision became final. 4. New evidence received since the final September 2009 final rating decision raises a reasonable possibility of substantiating the service connection claim for chronic pain syndrome disability. 5. The Veteran initiated her claim in the VDC system for an increased rating for the service-connected migraine disability, which was initially received by VA on October 21, 2014. 6. The evidence is at least in equipoise that the migraine disability more nearly approximated very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability as of October 21, 2013. 7. The currently diagnosed anemia is caused by the service-connected uterine fibroids and menorrhagia. 8. The currently diagnosed chronic abdominal pain, diagnosed as chronic pain syndrome, neuritis, and neuropathy, is a residual of the service-connected gallbladder removal and multiple hernia repair surgeries. 9. The currently diagnosed acquired psychiatric disability was caused by or is aggravated by the chronic abdominal pain and is a residual of the service-connected gallbladder removal and multiple hernia repair surgeries. CONCLUSIONS OF LAW 1. The July 2009 rating decision that denied the Veteran’s service connection claim for an anemia disability is final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 20.1103. 2. Evidence received after the final July 2009 rating decision is new and material for the claim for service connection for anemia disability, and the claim is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The September 2009 rating decision that denied the Veteran’s service connection claim for a chronic pain syndrome disability is final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 20.1103. 4. Evidence received after the previous final September 2009 rating decision is new and material for the claim for service connection for a chronic pain syndrome disability, and the claim is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 5. The criteria for an effective date of October 21, 2013 for an award of the 50 percent rating for the migraine disability are met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.156(b), 3.400(o), Diagnostic Code 8100. 6. The criteria for service connection for an anemia disability have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310. 7. The criteria for service connection for a chronic abdominal pain disability have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.303, 3.310. 8. The criteria for service connection for an acquired psychiatric disability and have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.303. 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1987 to May 2009. This matter comes on appeal before the Board of Veterans’ Appeals (Board) from an October 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In March 2020, the Veteran and her spouse testified before the undersigned Veterans Law Judge at a Central Office hearing in Washington, DC. A copy of the hearing transcript is of record and has been reviewed. As reflected on the title page of this decision, the Board broadens the service connection claim for depression and anxiety to a service connection claim for an acquired psychiatric disorder, to include adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, unspecified anxiety disorder, unspecified depressive disorder, and somatic symptom disorder with predominate pain, persistent, or however diagnosed, under the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DMS-5). See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). In addition, as reflected on the title page of this decision, the Board broadens the service connection claim for chronic pain syndrome, neuritis, and neuropathy to a service connection claim for abdominal pain, to include chronic pain syndrome, neuritis, neuropathy, or however diagnosed. Id. Preliminary Matters The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). New and Material Evidence Rating decisions are final and binding based on evidence on file at the time the claimant is notified of the decision and may not be revised on the same factual basis except by a duly constituted appellate authority. 38 C.F.R. § 3.104(a). The claimant has one year from notification of a RO decision to initiate an appeal by filing a NOD with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.160, 20.201, 20.302. An exception to the finality rule is found in 38 U.S.C. § 5108, which provides that, if new and material evidence is received with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held, however, that evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence had not been previously presented. Anglin v. West, 203 F.3d 1343, 1347 (2000). In deciding whether new and material evidence has been received, the Board looks to the evidence submitted since the last final denial of the claim on any basis. Evans v. Brown, 9 Vet. App. 273, 285 (1996). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). 1. As new and material evidence has been received, the service connection claim for anemia is reopened. The RO denied the Veteran’s service connection claim for anemia in a July 2009 rating decision, of which she was sent notice in August 2009, finding that there was no evidence of a current diagnosis of anemia and that any previously diagnosed anemia was the result of uterine fibroids, which had resolved. The evidence considered at the time included the Veteran’s Application for Compensation, service treatment records, service personnel records, DD Form 214, statements from the Veteran, and pre-discharge VA examinations. The Veteran did not appeal the decision, and new and material evidence was not received within one year of the decision notice letter. Thus, the July 2009 rating decision became final. See 38 U.S.C. § 7105(d)(3); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); 38 C.F.R. §§ 3.104, 3.156(a)-(b), 20.302, 20.1103. Relevant evidence received since the July 2009 rating decision includes a March 2020 letter from the Veteran’s private treatment provider noting a current diagnosis and treatment for anemia. This evidence, specifically the current diagnosis relates to the unestablished element of a current diagnosis in the prior denial. The additional evidence received since the July 2009 final denial is therefore new and material. The criteria for reopening the claim for service connection for an anemia disability are therefore met. 2. As new and material evidence has been received, the service connection claim for chronic pain syndrome is reopened. The RO denied the Veteran’s service connection claim for chronic pain syndrome in a September 2009 rating decision finding that there was no evidence of a current diagnosis of chronic pain syndrome disability on VA examination. The evidence considered at the time included the Veteran’s Application for Compensation, service treatment records, service personnel records, DD Form 214, statements from the Veteran, and pre- and post-discharge VA examinations. The Veteran filed a notice of disagreement with this decision, and a statement of the case was issued in October 2010. However, the Veteran did not perfect the appeal to the Board. Thus, the September 2009 rating decision became final. See 38 U.S.C. § 7105(d)(3); Bond, 659 F.3d at 1362; 38 C.F.R. §§ 3.104, 3.156(a)-(b), 20.302, 20.1103. Relevant evidence received since the September 2009 final denial includes a March 2016 VA treatment record which include chronic pain syndrome as an active medical problem. This evidence relates to the unestablished element of a current diagnosis in the prior denial. Therefore, the additional evidence received since the September 2009 final denial is new and material. The criteria for reopening the claim for service connection for chronic pain syndrome are met. Earlier Effective Date 3. An effective date of October 21, 2013 for the assignment of the 50 percent rating for the service-connected headache disability is granted. VA law and regulation provide that unless otherwise provided, the effective date of an award of increased evaluation shall be fixed in accordance with the facts found but shall not be earlier than the date of receipt of the application therefor. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. Regulations also provide that the effective date of an evaluation and award of compensation based on a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 C.F.R. § 3.400(o)(1). The effective date of an award of increased compensation may, however, be established at the earliest date as of which it is factually ascertainable that an increase in disability had occurred, if the application for an increased evaluation is received within one year from that date. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). There are three possible dates for an increased rating that may be assigned depending on the facts of the case: (1) If an increase in disability occurs after the claim is filed, the date that the increase is shown to have occurred (date entitlement arose) (38 C.F.R. § 3.400 (o)(1)); (2) If an increase in disability precedes the claim by a year or less, the date that the increase is shown to have occurred (factually ascertainable) (38 C.F.R. § 3.400 (o)(2)); or (3) If an increase in disability precedes the claim by more than a year, the date that the claim is received (date of claim) (38 C.F.R. § 3.400 (o)(2)). See Gaston v. Shinseki, 605 F.3d 979, 982-8 (Fed. Cir. 2010); Harper v. Brown, 10 Vet. App. 125, 126 (1997). The effective dates for “staged ratings” are established using the principle set forth at 38 C.F.R. § 3.400(o)(2), that is, the earliest date that it is factually ascertainable that the criteria for each disability rating were met. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). In determining when an increase is “factually ascertainable,” VA will look to all the evidence including testimonial evidence and expert medical opinions as to when the increase took place. VAOPGCPREC 12-98. Here, the October 2015 rating decision granted a 50 percent rating for the migraine headache disability based on the findings in the September 2015 VA headache examination. The October 2015 rating decision assigned June 15, 2015, the date the complete increased rating claim was received by VA, as the effective date for the increase. The Veteran contends the 50 percent rating assigned to the service-connected migraine headaches should be assigned an effective date earlier than June 15, 2015. Specifically, she has asserted that the effective date should be in 2009, the year she was discharged from service, or June 16, 2010, the date of her initial claim for service connection for a headache disability. See October 2016 notice of disagreement, December 2019 VA Form 9 and March 2020 hearing transcript. An August 2015 memorandum for record reported the Veteran applied for an increased rating for the headache disability through the VDC system. The VDC system allowed the Veteran to initiate an application for benefits using a VA Form 21-526EZ but did not require that the claim be submitted during the same session. The VDC system allowed the Veteran one year from the initiation of the application to submit the finalized claim; however, the initial application served as the effective date, if benefits were granted. The memorandum indicated the Veteran initiated the June 15, 2015 application on October 21, 2014. Therefore, October 21, 2014 is the date of the Veteran’s claim. The Board acknowledges the Veteran’s belief that the 50 percent rating should be retroactive to either 2009 or 2010. The Board also acknowledges the Veteran’s belief that the February 2011 rating decision did not consider a September 2010 medical assessment or 2010 headache log when it assigned the initial noncompensable rating. See December 2019 VA Form 9 and March 2020 hearing transcript. However, VA’s laws and regulations do not allow for such a retroactive award. The Veteran had one year from the February 2011 rating decision to express her written disagreement with the initial noncompensable rating, but she did not. Thus, the February 2011 rating decision became final. Consequently, there is no legal basis upon which to grant an effective date for any period before October 21, 2013 (one year before the current increased rating claim was received) for a compensable rating for the migraine disability. The Board is bound by the law and is without authority to grant benefits on an equitable basis. See 38 U.S.C. §§ 503, 7104; see also Harvey v. Brown, 6 Vet. App. 416, 425 (1994). The Board further observes that “no equities, no matter how compelling, can create a right to payment of the United States Treasury which has not been provided for by Congress.” See Smith v. Derwinski, 2 Vet. App. 429, 432-33 (1992), citing Office of Personnel Management v. Richmond, 496 U.S. 414, 426 (1990). The Board is bound by the law governing the assignment of effective dates in its determination in this case. See 38 U.S.C. § 7104(c). However, after reviewing the evidence, both lay and medical, the evidence is at least in equipoise that the Veteran’s headaches were very frequently completely prostrating with prolonged attacks productive of severe economic inadaptability in the year before the October 21, 2014 claim. Therefore, for these reasons, the Board finds that an effective date of October 21, 2013, but no earlier, is warranted. See 38 C.F.R. § 3.400(o)(2); see also Gaston, 605 F.3d at 979. Finally, the Board notes that neither the Veteran nor her representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also 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). Primary anemia is considered by VA to be a “chronic disease” listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions based on “chronic” in-service symptoms and “continuous” post-service symptoms under 38 C.F.R. § 3.303(b) apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a “chronic disease” in service or “continuity of symptoms” after service, the disease shall be presumed to have been incurred in service. Where there is a chronic disease shown as such in service or within the presumptive period under § 3.307 to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). This rule does not mean that any manifestation in service will permit service connection. 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 a condition noted during service is not shown to be chronic, then generally, a showing of “continuity of symptoms” after service is required for service connection. 38 C.F.R. § 3.303(b). Chronic pain syndrome and most psychiatric disabilities (excluding psychosis) are not considered by VA to be a “chronic disease” listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions based on “chronic” in-service symptoms and “continuous” post-service symptoms under 38 C.F.R. § 3.303(b) do not apply. Walker, 708 F.3d at 1331. Where a veteran served ninety days or more of active service, and certain chronic diseases, such as primary anemia, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. A layperson is competent to report on the onset and continuity of her current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 4. Service connection for anemia, as secondary to the service-connected uterine fibroids and menorrhagia, is granted. The evidence of record includes a March 2009 pre-discharge VA general medical examination. The medication review noted the Veteran was prescribed Ferrous Sulfate daily for anemia. The examiner, a physician, noted the Veteran was anemic, which the Veteran reported was related to uterine fibroid tumors and heavy menstrual periods. The examiner found no frank signs of anemia on examination. The examiner noted she had been diagnosed with uterine fibroids and menorrhagia but had not had a hysterectomy. The examiner concluded the Veteran had current diagnoses of anemia secondary to abrupt fibroid tumors. The Veteran was also afforded a March 2009 VA gynecological examination. The examiner, a physician, noted the Veteran had increasing symptoms of heavy menstrual bleeding, clots, and cramping. She initially sought treatment for these symptoms in 2006. An ultrasound confirmed the presence of uterine fibroids. She was prescribed oral contraceptive pills with minimal symptom improvement. On physical examination, the vulva was normal without lesions or abnormal discharge. The vaginal mucosa and the cervix were normal. No abnormal discharge or blood in the cervical os was found. Bimanual examination found the cervix was slightly retracted to the left. Palpation of the uterus did not reveal any abnormal masses. The adnexa were nontender without any abnormal masses. A pelvic ultrasound was ordered to confirm the presence of fibroids, given that no grossly large fibroids were found on bimanual examination. The examiner diagnosed the Veteran with menorrhagia and a history of uterine fibroids. VA sent the Veteran October 2011 and August 2012 letters with the results of her bloodwork. It noted the Veteran’s hemoglobin was 12.1 in October 2011 and 11.4 in August 2012. The letters indicated she was anemic, advised to take an over the counter iron supplement, and advised her to increase the protein in her diet. The Veteran was physically examined at the Women’s Center in September 2012. After examination, the assessment was anemia, menorrhagia, and to rule out uterine fibroids. In January 2013 and September 2013, the Veteran was sent a letter summarizing the results of recent bloodwork. Her hemoglobin was 11.6 in January 2013 and 11.3 in September 2013. Both letters advised the Veteran’s she was anemic and to take an iron supplement. A July 2014 VA treatment record noted the Veteran had anemia associated with menorrhagia and fibroids. She was on supplemental iron. A July 2015 VA treatment record listed anemia on the Veteran’s active problem list. The record also noted that it was presumed that she was iron deficient due to her menorrhagia. See also January 2013 VA treatment records. The Veteran submitted a March 2020 letter from Dr. D.A., the Veteran’s primary care physician. Dr. D.A. indicated the Veteran was diagnosed with anemia in August 2015, and she had received treatment for it since that time. After resolving all reasonable doubt in favor of the Veteran, the Board finds service connection for anemia as secondary to the service-connected uterine fibroids and menorrhagia is warranted. As an initial matter, the Veteran has a current diagnosis of anemia. See March 2020 private treatment letter. In addition, the Veteran is service connected for the uterine fibroids with menorrhagia, effective August 2019. See October 2019 rating decision. As discussed above, the Veteran was diagnosed and treated for anemia during service. Further, a March 2009 pre-discharge VA examination indicated that the Veteran’s history of anemia was due to uterine fibroids and menorrhagia, which are now service-connected disabilities. The record demonstrates that there is competent medical evidence of an etiological connection between the Veteran’s military service and the anemia disability. Significantly, the March 2009 positive VA nexus opinion is not contradicted by any other negative medical evidence or opinion of record. Therefore, after resolving all reasonable doubt in favor of the Veteran, service connection for the anemia disability is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102, 3.303, 3.034, 3.307, 3.309, 3.310. 5. Service connection for chronic abdominal pain (claimed as chronic pain syndrome, neuritis, and neuropathy), as a residual of the service-connected hernia and gallbladder surgeries, is granted. As an initial matter, the Veteran has been diagnosed with chronic pain syndrome and ilioinguinal neuropathy during the appellate period, which is characterized as symptoms of abdominal pain. See May 2016 private treatment records. The Veteran has also been service connected for residuals of a gallbladder removal surgery and three hernia repair surgeries. See July 2009 rating decision. In March 2009, the Veteran was afforded a pre-discharge VA general medical examination. The Veteran reported her gallbladder was removed during service in January 2004. She also had an umbilical hernia in April 2004, which was subsequently repaired twice in October 2004 and February 2006. On physical examination of the abdomen, bowel sounds were within normal limits. It was noted the Veteran had a series of abdominal scars. The abdomen was soft, nontender, and nondistended. June 2009 to September 2009 post-service treatment records note the Veteran had been diagnosed with chronic pain syndrome, neuritis, and neuropathy. Subsequently, the Veteran was afforded an August 2009 VA examination. The examiner, a physician, evaluated the Veteran for fibromyalgia due to deep abdominal pain, which she reported dated back to the surgical repairs for the recurrent umbilical hernias during service. A couple of months following the surgeries, the Veteran developed a deep pain in the lower left quadrant of her abdomen. She had been evaluated by various specialists to determine the source of the pain, including orthopedics and neurology. At the time of this examination, she was being seen by the pain management clinic at Walter Reed Hospital and was being treated for presumed peripheral neuropathy with Lyrica and a TENS unit. She had also been afforded iliohypogastric nerve ablation and cryoablation in the abdomen to deaden the pain. The Veteran declined to continue those treatments due to subsequent weight gain. She denied symptoms of fatigue, arthralgia, or myalgias and indicated the pain was localized to the left lower quadrant of her abdomen. Movement precipitated the pain. Rest, TENS unit, and Lyrica alleviated the pain. On physical examination, it was noted that specific musculoskeletal areas were involved, and no trigger or tender points were identified. Muscle strength was normal in all muscle groups. Fibromyalgia was ruled out as a diagnosis. The examiner noted the Veteran had chronic pain in the left lower quadrant of her abdomen, which was being treated by her treating clinicians as presumed peripheral neuropathy. See also January 2007 to May 2007, October 2008, January 2009 to May 2009 service treatment records. September 2009 treatment records noted the Veteran had left lower quadrant abdominal pain. The pain was recurrent, dull, boring or aching, but it did not radiate. It had not increased in frequency and did not wake her from sleep. It did not occur within 30 minutes of eating. It was not caused by fasting, drinking coffee, alcohol or milk, or taking medications. It was not caused by lying down, urination, or bowel movements. It started or intensified with body movement and coughing and gradually resolved on its own. No melena, hematochezia, or diarrhea was found. The assessment was abdominal pain, possibly from a small hernia. July 2010 medical records reported the Veteran experienced chronic left side abdominal pain since the most recent umbilical hernia repair surgery in 2006. She had multiple pulsed RF iliohypogastric nerve ablations, which helped more than 50 percent for one month. More recently, the Veteran underwent cryoablation, which had been the most effective, providing 75 percent relief for about a month. Lyrica moderated the pain, but other medications had not been effective. The pain was described as sharp and crampy. It was not positional, worsened with activity, and decreased in severity with rest. No assessment was provided. See also August 2010 medical treatment records. A September 2012 CT scan showed a small hiatal hernia. May 2016 private treatment records diagnosed the Veteran with chronic pain syndrome and ilioinguinal neuropathy. The Veteran submitted a lengthy letter with her October 2016 notice of disagreement. The Veteran asserted the abdominal pain began during service, that she was treated for it during service, and that it was noted on her retirement physical examination. She listed each time she was treated for the abdominal pain, beginning in January 2004. After the gallbladder removal surgery and the three hernia repair surgeries, she continued have left lower quadrant pain. See November 2006 to April 2009 service treatment records. During this time, she was diagnosed with neuropathic pain, neuritis, and chronic pain syndrome. She was referred to pain management and was treated with intralesional injections, a TENS machine, iliohypogastric blocks, acupuncture, iliohypogastric nerve RF denervation, and peripheral nerve ablation. She continued to have deep persistent pain that was described as tingling, burning, stabbing, and sharp. She also experienced numbness. She asserted these symptoms were consistent with the symptoms that were diagnosed in service as chronic pain syndrome, neuritis, and neuropathy of the lower left quadrant of her abdomen. She reported that she continued to be treated by pain management for chronic pain syndrome, left groin pain, left ilioinguinal neuropathy, and myalgia (myofascial pain syndrome). Since September 2015, the Veteran had been treated by pain management. She had been treated for chronic pain syndrome, ileoinguinal neuropathy, and myalgia (myofascial syndrome), and other specific mononeuropathies of the left lower limb. She was currently receiving treatment by a psychologist for pain management. She indicated that she believed that the gallbladder surgery and 3 hernia repair surgeries damaged the peripheral nerve and led to the continuous persistent dull, sharp, burning, stabbing and shooting pain and tingling symptoms. She asserted that she had these same symptoms during service, and that they had continued since service. July 2019 VA treatment records noted that the Veteran had chronic pelvic pain with questionable etiology. The Veteran submitted two medical journal articles in March 2020. One was an abstract for a February 2001 medical journal article entitled, “Long-term follow up of 1059 consecutive primary and recurrent inguinal hernias to a teaching hospital.” The abstract indicated that, after a medial follow up of 5.5 years, the recurrence rate was 8 percent for primary hernia repairs and 29 percent after recurrent hernias. The incidence of permanent pain or discomfort was unexpectedly high at 11 percent after primary repairs and 15 percent after recurrent hernia repairs. The second medical journal article is entitled, “Chronic Pain after Inguinal Hernia Repair” which was published in December 2014. The article found that chronic post-hernia groin pain, defined as pain lasting greater than 6 months, occurred with greater frequency than previously though. The article suggested that post-surgical chronic pain was dependent on several factors, to include preoperative pain, type of anesthesia used, nerve injury, postoperative local infiltration, postoperative complications, and postoperative pain. The Veteran submitted a March 2020 letter from Dr. L.T., her treating psychologist for pain management. Dr. L.T. noted the in-service gallbladder and hernia surgeries had resulted in chronic pain. Dr. L.T. was concurrently being treated by a medical pain specialist. Dr. L.T. noted the Veteran had no other risk factors that might have precipitated the current symptoms. After a review of the pertinent records, Dr. L.T. concluded that it was at least as likely as not that the Veteran’s abdominal pain was a direct result of the in-service gallbladder and hernia surgeries. In Dr. L.T.’s personal experience and based on the psychological literature, Dr. L.T. indicated that it is known that these types of surgeries often resulted in chronic pain. After a review of the evidence, both lay and medical, the Board notes the Veteran has been diagnosed and treated for recurrent and continuous abdominal pain, variously diagnosed as chronic pain syndrome, neuritis, neuropathy, and abdominal pain, as a result of the in-service gallbladder removal surgery and multiple hernia repair surgeries. As an initial matter, the Board notes there is no negative medical opinion of record to controvert the positive March 2020 private medical opinion. Furthermore, in July 2009, the RO awarded service connection for a keloid scar and “multiple arthroscopic scars, status post gallbladder removal and umbilical hernia repairs,” as reflected on the rating code sheet. Based on the July 2009 rating decision and the findings therein, the Board finds that service connection for residuals of the gallbladder removal surgery and three hernia repair surgeries have already been granted. The RO’s findings are clear that the Veteran has multiple scars as a result of the multiple in-service surgeries, and that these surgeries were the basis for the award of service connection. Therefore, the award of service connection for residuals of the gallbladder removal surgery and three hernia repair surgeries have already been implicitly granted by the award of service connection for the surgical scars. See Baughman v. Derwinski, 1 Vet. App. 563, 566 (1991) (listing a condition on a rating decision as part of a service-connected disability has the effect of granting service connection). For these reasons, the Board will explicitly award service connection for chronic abdominal pain, however diagnosed, as a residual of the gallbladder and multiple hernia repair surgeries, in order to avoid any further confusion in this matter. See 38 C.F.R. §§ 3.102, 3.303. 6. Service connection for an acquired psychiatric disability, as secondary to the gallbladder and hernia surgery residuals, is granted. As an initial matter, the Veteran has been diagnosed with acquired psychiatric disorders during the appellate period, to include adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, unspecified anxiety disorder, unspecified depressive disorder, and somatic symptom disorder with predominate pain, persistent under the DSM-V. See September 2015 and September 2016 VA treatment records and January 2020 private treatment records. As noted above, the Veteran is also service connected for residuals of an in-service gallbladder removal and three hernia repairs. See July 2009 rating decision. The Veteran contends that due to chronic abdominal pain, which is a residual of the in-service gallbladder removal surgery and three hernia repair surgeries (which is granted service connection herein), she has developed psychiatric disabilities. See October 2016 notice of disagreement and March 2020 hearing transcript. The Veteran submitted a letter from Dr. L.T., her treating private psychologist. Dr. L.T. had been treating the Veteran with psychotherapy since September 2016. Dr. L.T. concluded that the in-service gallbladder removal surgery and three hernia repair surgeries had resulted in chronic pain. Dr. L.T. diagnosed the Veteran with recurrent Major Depressive Disorder and Somatic Symptom Disorder with Persistent Predominate Pain under the DSM-5. The Veteran had no other risk factors that might have precipitated her current condition. After a review of the pertinent records, Dr. L.T. concluded that it was at least as likely as not that the Veteran’s psychiatric conditions were a direct result of the residuals of the in-service gallbladder removal surgery and three hernia surgeries, specifically the chronic abdominal pain. The Veteran also submitted two medical articles in support of her claim, including a December 2014 article entitled “Chronic Pain after Inguinal Hernia Repair” and a February 2001article entitled, “Long-term follow up of 1059 consecutive primary and recurrent inguinal hernias to a teaching hospital,” which are further discussed above. As discussed above, the RO’s findings are clear in the July 2009 rating decision that the Veteran’s multiple in-service surgeries were the basis for the award of service connection for the scars. The Board has also awarded service connection for the chronic abdominal pain as a residual of the in-service surgeries herein. Therefore, the award of service connection for residuals of these surgeries have already been implicitly granted by the award of service connection for the surgical scars. See Baughman, 1 Vet. App. at 563, 566. The Veteran has submitted a competent private medical opinion that finds that the service-connected residuals of the in-service surgeries, specifically the chronic abdominal pain, has caused or aggravated her psychiatric disabilities. There is no negative medical opinion of record that contradicts the March 2020 medical opinion. For these reasons, after resolving any reasonable doubt in favor of the Veteran, service connection for the acquired psychiatric disabilities is warranted. See 38 C.F.R. §§ 3.102, 3.303, 3.310. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Harper, 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.