Citation Nr: 21002814 Decision Date: 01/15/21 Archive Date: 01/15/21 DOCKET NO. 13-16 734 DATE: January 15, 2021 ORDER Service connection for fibrocystic breast disease is denied. Service connection for angina pectoris with chest pains is denied. REMANDED The claim for service connection for fibromyalgia is remanded. The claim for service connection for irritable bowel syndrome (IBS) is remanded. The claim for service connection for hypertension, based on direct service connection or secondary causation, is remanded. FINDINGS OF FACT 1. The probative evidence of record does not show a current diagnosis of fibrocystic breast disease. 2. The probative evidence of record does not show a current diagnosis of angina pectoris with chest pains. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for fibrocystic breast disease have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.303 (2020). 2. The criteria for establishing entitlement to service connection for angina pectoris with chest pains have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1980 to March 1981, from February 1991 to April 1991, and from February 1995 to September 1995, with additional reserve service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In November 2013, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. This matter was most recently before the Board in August 2018, at which time it was remanded for further development. The requested development was completed, and the case has been returned to the Board for further appellate action. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303. Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). 1. Entitlement to service connection for fibrocystic breast disease The Veteran seeks service connection for fibrocystic breast disease, which she asserts was caused by vaccinations she received when she was called up to active duty in February 1991. During the November 2013 Board hearing, the Veteran testified that about five or six years after receiving in-service vaccinations, she was diagnosed with fibrocystic breast disease, which is manifested by painful cysts and requires yearly monitoring. Upon review of the record, the Board finds that the probative evidence of record does not show a current diagnosis of fibrocystic breast disease. Service treatment records contain a January 1982 periodic reserve examination, which notes fibrocystic changes in the breasts prior to the Veteran’s second period of active duty. Post-service treatment records show that in April 2004, the Veteran reported bilateral breast tenderness, and a mammogram and ultrasound revealed fibrocystic changes bilaterally. In March 2006, the Veteran reported subjective changes in the left breast and a painful lump in the right breast. A mammogram revealed probable cysts within the breasts, and the treatment provider recommended a follow-up ultrasound in six months. Treatment records dated through 2007 list fibrocystic breast disease on the Veteran’s problem list; however, they do not show any additional complaints of or treatment for the condition. In March 2010, the Veteran filed her claim for service connection fibrocystic breast disease. Subsequent treatment records do not show a diagnosis of or treatment for fibrocystic breast disease. A bilateral mammogram and ultrasound performed in March 2013 was negative. An April 2018 women’s health consultation note shows that a breast examination revealed no masses, skin or nipple changes, or supraclavicular or axillary adenopathy. The Veteran underwent a VA breast examination in September 2015, at which time the examiner reviewed the evidence of record and indicated that the Veteran did not have a current breast disability.   In September 2017, another VA examiner reviewed the evidence of record and opined that the fibrocystic breast disease documented in prior treatment records was less likely than not incurred in or cause by service, to include as due to in-service vaccines. In January 2020, another VA examiner reviewed the evidence of record and indicated that the Veteran did not have a current diagnosis of fibrocystic breast disease. In support of this, the examiner explained that the Veteran’s most recent mammogram did not show any evidence of fibrocystic breast disease, and a gynecological evaluation performed in April 2018 did not diagnose or note a history of fibrocystic breast disease. The Board finds that the prior diagnosis of fibrocystic breast disease is not sufficiently proximate to the Veteran’s claim to support a finding that she has a current diagnosis of fibrocystic disease, as it was most recently noted on imaging in March 2006, four years prior to filing her service connection claim. Moreover, treatment records after 2007 do not show a diagnosis of or treatment for fibrocystic breast disease, and the January 2020 VA examiner reviewed the Veteran’s treatment records, including a March 2013 mammogram and April 2018 breast examination, and indicated that the Veteran did not have a current diagnosis of fibrocystic breast disease. See Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Nor does the evidence suggest a disability of the breast that results in functional impairment in earning capacity. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). To the extent that the Veteran believes that she has a current diagnosis of fibrocystic breast disease, as a lay person, she has not shown that she has specialized training sufficient to render such an opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In this regard, the diagnosis of fibrocystic breast disease is not a matter capable of lay observation and requires medical expertise to determine. Thus, the opinion of the Veteran regarding a current diagnosis of fibrocystic breast disease is not competent medical evidence.   In sum, the preponderance of the competent and probative evidence is against the claim, and service connection is denied. 2. Entitlement to service connection for angina pectoris The Veteran seeks service connection for angina pectoris with chest pains, which she asserts was caused by vaccinations she received when she was called up to active duty in February 1991. During the November 2013 Board hearing, the Veteran testified that she began having chest pains about six or seven years after receiving the vaccinations. Upon review of the record, the Board finds that the probative evidence of record does not show a current diagnosis of angina pectoris. Service treatment records contain an April 1985 reserve treatment record showing that the Veteran reported chest pain, which worsened with deep breaths, coughing, and running. It was noted that she was previously seen for chest pain in August 1984, and the assessment was probable chest wall pain. A December 2004 private treatment record shows that a cardiolite examination revealed a small reversible perfusion defect involving the distal anteroseptal segment of the myocardium, suspicious for a small area of adenosine-induced reversible ischemia and clinical and electrocardiogram (EKG) correlation is advised. In May 2005, the Veteran reported undergoing an EKG, which was within normal limits. An April 2006 treatment record shows that the Veteran reported having a history of coronary artery disease (CAD) with angina. However, a May 2006 treatment record shows that the Veteran had a history of chronic, intermittently recurrent episodes of chest pain, for which she took nitroglycerin as needed, but EKGs have not shown any specific significant findings. A February 2007 treatment record notes a history of chest pain with a normal electrocardiogram (ECG). The assessment was angina pectoris atypical, and the Veteran was scheduled for a coronary angiography. The following day, the Veteran underwent a coronary angiography, which revealed no coronary artery disease and normal left ventricular systolic function. Subsequent treatment records show no treatment for chest pain or diagnosis of angina pectoris. In February 2010, the Veteran underwent a Persian Gulf War Registry examination, during which she stated that “another possible undiagnosed illness is non-cardiac chest pain…” She stated that she previously underwent coronary artery studies, chest x-rays, and ECGs, which were all normal. In March 2010, the Veteran filed her claim for service connection angina pectoris and chest pain. Thereafter, treatment records from March 2010 through June 2011 show that Veteran consistently denied any symptoms of chest pain on numerous occasions. In July 2011, the Veteran did not report any current symptoms of chest pain, but it was noted that she mentioned a history of chest pain and an old prescription for nitroglycerin from a private physician. The treatment provider advised her to seek medical attention if she ever had chest pain again. Subsequent treatment records show that that the Veteran continued to consistently deny symptoms of chest pain on numerous occasions. The Veteran underwent a VA examination in September 2015, at which time the examiner indicated that the Veteran did not have a diagnosis of a heart condition. In September 2017, another VA examiner reviewed the evidence of record and indicated that while the Veteran has reported multiple aches and pains, she did not have a diagnosis of ischemic heart disease or cardiogenic angina pectoris. In January 2020, another VA examiner reviewed the evidence of record and likewise indicated that the Veteran did not have a diagnosis of angina pectoris, which is a coronary artery diagnosis. The examiner indicated that any chest pain the Veteran may have reported is likely pain from fibromyalgia. The Board finds that the Veteran’s diagnosis of angina pectoris with chest pains is not sufficiently proximate to the Veteran’s claim to support a finding that the Veteran has a current diagnosis of angina pectoris, as it was made in February 2007, three years prior to filing her service connection claim. Additionally, the Veteran underwent a coronary angiography the following day, which revealed no coronary artery disease and normal left ventricular systolic function, and the treatment provider did not diagnose the Veteran with angina pectoris. Moreover, subsequent treatment records do not show a diagnosis of angina pectoris, and the Veteran consistently denied current symptoms of chest pain to her treatment providers ever since her service connection claim was filed in March 2010. Further, three VA examiners reviewed the evidence of record and indicated that she did not have a diagnosis of angina pectoris or any other heart condition. See Romanowsky, 26 Vet. App. at 293. To the extent that the Veteran believes that she has a current diagnosis of angina pectoris, as a lay person, she has not shown that she has specialized training sufficient to render such an opinion. See Jandreau , 492 F.3d at 1377. In this regard, the diagnosis of heart disabilities is not a matter capable of lay observation and requires medical expertise to determine. Thus, the opinion of the Veteran regarding a current diagnosis of angina pectoris is not competent medical evidence. In sum, the preponderance of the competent and probative evidence is against the claim, and service connection is denied. In reaching the above conclusions, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claims, the doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). REASONS FOR REMAND 1. The claim for service connection for fibromyalgia is remanded. 2. The claim for service connection for IBS is remanded. During the November 2013 Board hearing, the Veteran testified that she began experiencing pain and flu-like symptoms immediately after her in-service vaccinations. She also submitted written statements from her father, who indicated that the Veteran’s health deteriorated after her vaccinations in preparation for her deployment. In August 2017 and August 2018 remands, the Board directed the agency of original jurisdiction (AOJ) to obtain new medical opinions, and in doing so, directed the examiner to address the assertions of the Veteran and her father that that the Veteran’s health deteriorated after her vaccinations in preparation for a deployment. To the extent that the Board’s prior remand directives may be interpreted as finding the Veteran’s assertions of continued pain and/or deteriorating health ever since her in-service vaccinations to be credible, the Veteran is on notice that the Board has not made a determination regarding the credibility of such assertions. See Smith v. Wilkie, 32 Vet. App. 332, 339 (2020) (an appellant must first be given notice and an opportunity to respond before the Board reverses a prior Board remand’s characterization of evidence as credible). The Veteran may respond to this notice while the matter is on remand. 3. The claim for service connection for hypertension, based on direct service connection or secondary causation, is remanded. As an initial matter, the Board notes that in September 2020, service connection was granted for hypertension based on aggravation by service-connected disabilities. However, this is not considered a full grant, as an award of secondary service connection based on aggravation involves a deduction of the baseline level of disability from the Veteran’s rating. Indeed, the September 2020 rating decision indicated that the award was considered a partial grant of the issue on appeal. Therefore, the issue of entitlement to service connection for hypertension based on direct service connection or secondary causation remains on appeal. In August 2018, the Board remanded the claim to obtain an opinion from a physician as to whether the Veteran’s hypertension is secondary to her service-connected posttraumatic stress disorder (PTSD) and/or obstructive sleep apnea. In January 2020, a VA physician reviewed the evidence of record and opined that that the Veteran’s hypertension was aggravated by her service-connected PTSD and sleep apnea, but it was not caused by them. However, the examiner did not provide a rationale to support the opinion as to causation. Accordingly, a remand is necessary in order to obtain a new medical opinion. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”).   Additionally, during the November 2013 Board hearing, the Veteran testified that she had high blood pressure readings during active duty service. In August 2017, the Board remanded the claim to obtain new medical opinions, and in doing so, the Board directed the examiner to address the Veteran’s assertion that she had high blood pressure readings during service. To the extent that the Board’s August 2017 remand directives may be interpreted as finding the Veteran’s assertion of having high blood pressure readings during service to be credible, the Veteran is on notice that the Board has not made a determination regarding the credibility of that assertion. See Smith v, 32 Vet. App. at 339. The Veteran may respond to this notice while the matter is on remand. The matters are REMANDED for the following action: Obtain an addendum medical opinion with respect to the Veteran’s claim for service connection for hypertension. Do not schedule the Veteran for another examination unless it is deemed necessary by the examiner to respond to the questions presented. After a review of the claims file, the physician should answer the following: (a.) Is it at least as likely as not (50 percent or higher probability) that the Veteran’s hypertension was caused by her service-connected PTSD? Please explain why or why not. (b.) Is it least as likely as not (50 percent or higher probability) that the Veteran’s hypertension was caused by her service-connected sleep apnea? Please explain why or why not. A complete rationale for all opinions must be provided. The examiner’s opinion should reflect consideration of the medical literature referenced in an August 2018 post-remand brief regarding an association between PTSD, sleep deprivation, and hypertension (VBMS – Appellate Brief (VSO IHP, Post Remand Brief; Attorney Brief), received 8/10/18). K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Banister, 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.