Citation Nr: 20046520 Decision Date: 07/13/20 Archive Date: 07/13/20 DOCKET NO. 15-42 507A DATE: July 13, 2020 ORDER Entitlement to service connection for a right lower extremity vascular disability, to include varicose veins, and to include as secondary to left lower extremity varicose veins, is denied. FINDING OF FACT The Veteran’s right lower extremity vascular disability, to include varicose veins, did not have its onset during active service; is not otherwise etiologically related to an in-service injury, disease, or event; is not proximately due to left lower extremity varicose veins; and has not been aggravated by left lower extremity varicose veins. CONCLUSION OF LAW The criteria for service connection for a right lower extremity vascular disability, to include varicose veins, and to include as secondary to left lower extremity varicose veins, are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Air Force from July 1955 to July 1959. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2014 rating decision by an Agency of Original Jurisdiction (AOJ) of the Department of Veterans Affairs (VA). The Veteran testified before the undersigned in October 2018. In February 2019, the Board granted entitlement to service connection for insomnia, denied entitlement to service connection for obstructive sleep apnea, and remanded the issues of entitlement to service connection for bilateral hearing loss and right lower extremity varicose veins. A March 2019 rating decision implemented the February 2019 Board decision. The March 2019 rating decision granted service connection for insomnia and assigned an initial 30 percent rating effective March 15, 2013. From June 4, 2013, insomnia was combined with posttraumatic stress disorder (PTSD) and assigned a 70 percent rating. An October 2019 rating decision granted entitlement to a total disability rating due to individual unemployability (TDIU) effective June 4, 2013. Pursuant to a June 2020 rating decision, the Veteran was granted service connection for bilateral hearing loss. Thus, that issue is no longer before the Board. The Board acknowledges the Veteran’s correspondence seeking to perfect an appeal under VA’s modernized review system of the March 2020 Statement of the Case (SOC). See May 2020 Correspondence. That matter will be addressed separately. Turning to the merits of the appeal, the Veteran asserts that his right lower extremity varicose veins are caused by his service-connected left lower extremity varicose veins. See, e.g., October 2018 Hearing Transcript at 9-10; March 2013 VA Form 21-526b; March 2014 Notice of Disagreement (NOD). Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. To establish entitlement to service connection, a veteran must show (1) a present disability; (2) an 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. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Additionally, secondary service connection may be granted for a disability that is proximately due to or aggravated by a service-connected disease or injury. 38 U.S.C. § 1131; 38 C.F.R. § 3.310. As the Veteran’s primary contention is that his right lower extremity varicose veins are secondary to his left leg varicose veins, the Board will address secondary service connection first. Here, the Veteran has a current diagnosis of right lower extremity varicose veins. See, e.g., October 2019 Artery and Vein Conditions Examination Report. Moreover, he is in receipt of service connection for left lower extremity varicose veins. Thus, the first and second elements of secondary service connection are met, and this appeal turns on whether there is a nexus linking these disabilities. Of record are a series of adequate medical opinions from two examiners, specifically a February 2019 examiner and an October 2019 examiner. The February 2019 opinions were secured by the AOJ in response to a claim from the Veteran, and the October 2019 opinions were secured in response to the Board’s remand directives. The October 2019 opinions substantially comply with the Board’s remand directives, as they address the venous insufficiency noted by 2017 examiner, as well as the Veteran favoring his leg over many years, and the opinions include adequate rationales. Although the examiner did not employ different boxes in the medical opinion form to address proximate cause and aggravation, this is a technicality, and the opinion amply demonstrates the examiner’s distinct opinions as to each theory of secondary service connection. Moreover, and as discussed below, the opinions permit the Board to make a fully-informed decision and are adequate for rating purposes. In any event, to the extent that the examiner did not strictly comply with the remand directives, there has been substantial compliance, as the examiner addressed the key question of whether there was a relationship between the varicose veins in the left lower extremity and the varicose veins of the right lower extremity. The October 2019 examiner explained that the Veteran’s right lower extremity varicose veins increased in severity over baseline, as varicose veins were not noted by prior examiners and developed during the period appeal. However, the examiner explained that this increase was due to the natural progress of the disease and not do to left leg varicose veins. Specifically, the examiner explained that while venous insufficiency is present somewhat in the right lower extremity, the Veteran was most likely susceptible to venous insufficiency “to begin with” and that his varicose veins on the left side did not cause varicose veins on the right side. Furthermore, he explained that the Veteran had risk factors for developing varicose veins and that having them on the left side does not increase the risk on the right side. This opinion adequately addresses a theory of secondary service connection due to proximate cause, as well as secondary service connection due to aggravation. In this regard, the examiner explained that the Veteran’s right lower extremity varicose veins are due to risk factors and venous insufficiency that are unrelated to service-connected left lower extremity varicose veins, and that left lower extremity varicose veins did not “cause” or “increase the risk” of right lower extremity varicose veins that progressed due to the natural progress of disease. Simply put, the examiner explained that right lower extremity varicose veins were most likely not caused or worsened by left lower extremity varicose veins. The October 2019 examiner’s opinion as to secondary service connection is supported by the February 2019 examiner’s opinion. In this regard, the February 2019 examiner explained that varicose veins are caused by weak or damaged valves in the veins and valve insufficiency in one leg does not lead to valve insufficiency in the other leg. Again, this evidence weighs against showing the presence of an etiological relationship. The Board acknowledges that the Veteran believes that his right lower extremity varicose veins are related to his left lower extremity varicose veins. However, an opinion as to the etiology of an internal vascular condition requires specialized medical training, knowledge, and expertise. The record does not demonstrate that the Veteran has such knowledge. Thus, the Veteran is not competent to provide an opinion as to the etiology of his right lower extremity varicose veins. The Board emphasizes that while reporting the presence of varicose veins does not require any specialized expertise, that is distinct from the question of etiology. Critically, the Veteran does not assert that his right lower extremity varicose veins developed in service. Accordingly, as the entirety of the probative of record shows that right lower extremity varicose veins are not proximately due to or aggravated by left lower extremity varicose veins, secondary service connection for right lower extremity varicose veins is not warranted. With respect to direct service connection, the October 2019 examiner noted that there are no records showing right lower extremity varicose veins in service and that the Veteran’s left leg vein-stripping procedure shortly after service would not cause right leg varicose veins. Critically, the examiner explained that the right lower extremity varicose veins are most likely due to inherent risk factors, as the Veteran “is probably susceptible to venous insufficiency to begin with.” Thus, the evidence shows that the varicose veins are due to a cause other than an injury, disease, or event in service. The Board acknowledges Veteran’s service treatment records (STRs) are unavailable and are presumed to have been destroyed in a 1973 fire at the government storage facility. See, e.g., March 2011 Third Party Correspondence. Notwithstanding this unavailability, the Veteran was granted service connection for left leg varicose veins based on his competent and credible reports symptoms in service and post-service treatment. However, the Veteran does not assert that he developed or was treated for right lower extremity varicose veins in service, and the Board has conceded the Veteran’s reports of his symptoms in service. Thus, the contents of the STRs would not aid the Veteran in his claim. Finally, the Board acknowledges the Veteran’s report that it is “possible” that he had some issues with his right leg in service. See December 2015 Correspondence. However, this statement is equivocal, and critically the October 2019 examiner’s opinion addressing direct service connection explained that favoring of one leg over another leg alone is not a risk factor for developing varicose veins. Accordingly, as the probative evidence of record is against the claim, entitlement to direct and secondary service connection for a right lower extremity vascular disability, to include varicose veins, is denied. S. BUSH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D.M. Badaczewski, 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.