Citation Nr: 20031030 Decision Date: 05/04/20 Archive Date: 05/04/20 DOCKET NO. 13-36 082 DATE: May 4, 2020 ORDER Entitlement to service connection for a kidney disability, diagnosed as obstructive nephropathy with renal tubular damage and enuresis, is granted. Entitlement to service connection for a heart disability, diagnosed as hypertension and coronary artery disease resulting in myocardial infarction, to include as secondary to a kidney disability, is granted. FINDINGS OF FACT 1. The most probative evidence reflects that obstructive nephropathy with renal tubular damage and enuresis was incurred during the Veteran’s active duty. 2. The most probative evidence reflects that hypertension and coronary artery disease resulting in myocardial infarction was caused by the Veteran’s kidney disability. CONCLUSIONS OF LAW 1. The criteria to establish service connection for a kidney disability, diagnosed as obstructive nephropathy with renal tubular damage and enuresis, have been met. 38 U.S.C. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2018). 2. The criteria to establish service connection for a heart disability, diagnosed as hypertension and coronary artery disease resulting in myocardial infarction, have been met. 38 U.S.C. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from October 1967 to May 1968. This matter comes to the Board of Veterans' Appeals (Board) from a May 2010 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) of the Veterans Benefits Administration (VBA), which is the Agency of Original Jurisdiction (AOJ). The Veteran expressed timely disagreement with this determination, and the present appeal ensued. In February 2014, the Veteran testified at a Board hearing conducted by the undersigned Veterans Law Judge (VLJ) via videoconferencing equipment. A transcript of the February 2014 hearing is associated with the file. In November 2014 and April 2017, the Board, among other actions, remanded the issues on appeal for further evidentiary and procedural development which has been substantially completed. Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran’s appeal has been returned to the Board for further appellate consideration. In September 2019, the Veteran’s private attorney submitted evidence in support of the Veteran’s appeal to the AOJ. For reasons unclear to the Board, the AOJ recertified and transferred the Veteran’s appeal to the Board in March 2020 without readjudicating the Veteran’s appeal in light of this new evidence. Although the September 2019 submission from the Veteran’s private attorney was not accompanied by a waiver of initial review of such by the AOJ, the Board may do so in the first instance. See 38 C.F.R. §§ 19.31, 19.37, 20.1304 (2018). Characterization of the issues on appeal While the Veteran’s initial claims were seeking to establish a heart disability and a kidney disability, these issues have been expanded based on the various and varying heart- and kidney-related disabilities diagnosed during the appeal period. Clemons v. Shinseki, 23 Vet. App. 1 (2009). 1. Entitlement to service connection for a kidney disability, diagnosed as obstructive nephropathy with renal tubular damage and enuresis. 2. Entitlement to service connection for a heart disability, diagnosed as hypertension and coronary artery disease resulting in myocardial infarction. Service connection may be established for a disability resulting from diseases or injuries which are clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C. § 1110 (West 2002); 38 C.F.R. § 3.303 (2017). Establishing service connection on a direct basis generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may also be granted for disability which is proximately due to or the result of service-connected disability. 38 C.F.R. § 3.310 (a) (2017). 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). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may include statements conveying sound medical principles found in medical treatises. Competent medical evidence may include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). 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 the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board notes that it has reviewed all of the evidence in the record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as to the claim being decided. Analysis Because analysis of these issues involves application of identical laws to similar facts, the Board will address them together for the sake of economy. The Veteran asserts that his documented enuresis (involuntary nocturnal urination) and excessive daytime urination were early manifestations of a kidney disability that, as it progressed, caused several heart-related disabilities. For the reasons expressed below, the Board concludes that the most probative evidence bolsters the Veteran’s assertions, and thus, service connection for these disabilities is warranted. As an initial matter, the Board observes that there is substantial evidence suggesting that the Veteran’s enuresis pre-existed his service; however, this evidence does not reflect a diagnosed disability underlying this symptom, and the Veteran’s entrance examination is devoid of such a notation. As such, the Veteran is considered to have been in sound condition upon service entrance regarding any kidney-related disability. The evidence of record demonstrates that the Veteran has been diagnosed with obstructive nephropathy with renal tubular damage and enuresis, hypertension, and coronary artery disease resulting in myocardial infarction, during the appeal period. As such, element (1) necessary to establish service connection is amply demonstrated regarding both appealed issues. Concerning element (2) to establish direct service connection, the Veteran’s service treatment records are replete with medical evidence reflecting the Veteran’s in-service episodes of enuresis and elevated blood pressure readings. To this extent, element (2) to establish direct service connection is met regarding both appealed issues. Concerning critical element (3), evidence of a causative medical nexus between the Veteran’s current disabilities and his service and/or a service-connected disability, there are two such opinions of record, and the Board will address them in turn. The Veteran was provided a VA examination in connection with his appeal in June 2018, and the examiner opined after a review of the file and a physical examination that his kidney and heart disabilities were less likely as not incurred during his active duty. In a statement rationalizing these opinions, the examiner noted the Veteran’s service treatment records, to include his entrance and separation examination reports, are devoid of any heart- and/or kidney-related conditions. As it was determined by the examiner that neither disability was incurred during the Veteran’s active duty, opinions addressing the theory of secondary causation were not offered. In support of his appeal, the Veteran submitted an August 2019 favorable opinion from Dr. C.N.B. After a review of the complete file and a physical examination of the Veteran, Dr. C.N.B. opined that the Veteran’s in-service “enuresis was likely due to exacerbations of his urethral valves, which subsequently disturbed his bladder function[,] leading to obstructive nephropathy and renal tubular damage.” The private physician further opined that the Veteran’s renal disease at least as likely as not caused the Veteran’s hypertension, which in turn, led to the development of coronary artery disease, resulting in myocardial infarctions. In support of these opinions, Dr. C.N.B cited and submitted medical literature supporting the interplay between kidney diseases and resulting cardiac complications. The Board concludes that the June 2018 VA examiner’s opinions are inadequate, and thus, are afforded little probative weight. Specifically, the opinions do not consider whether the Veteran’s in-service excessive urination and enuresis were nearly manifestations of an underlying kidney disability, which in turn, resulted in the Veteran’s heart-related disabilities, which is the crux of the Veteran’s appeal regarding these issues. On the contrary, the Board finds the August 2019 statements and opinions from Dr. C.N.B. to be persuasive concerning all criteria necessary to establish service connection, as they are based on accurate facts, to include the Veteran’s lay statements and assertions, and are supported by medical literature and a rationale based on such. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Bloom v. West, 12 Vet. App. 185, 187 (1999). In sum, the Board finds that the most probative evidence reflects that the Veteran incurred a kidney disability during his active duty, which, in turn, caused his heart-related disabilities. Therefore, the Board finds that service connection for the Veteran’s diagnosed obstructive nephropathy with renal tubular damage and enuresis, hypertension, and coronary artery disease resulting in myocardial infarction is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Scott W. Dale, 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.