Citation Nr: 21004962 Decision Date: 01/28/21 Archive Date: 01/28/21 DOCKET NO. 10-45 177 DATE: January 28, 2021 ORDER Service connection for gastrointestinal (GI) disorder is denied. Service connection for a kidney disorder is denied. REMANDED Service connection for hypertension. FINDINGS OF FACT 1. The Veteran had active service from January 1978 to May 1984. 2. A GI disorder, diagnosed as diverticulosis, was not shown in service and is not causally or etiologically related to service. 3. A kidney disorder was not shown in service, was not continuous since service or shown to a compensable degree within one year of separation from service, was not shown for many years after service, and is not causally or etiologically related to service. CONCLUSIONS OF LAW 1. A GI disorder was not incurred in service. 38 U.S.C. §§ 1101, 1112, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2020). 2. A kidney disorder was not incurred in service and may not be presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1112, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In March 2018, the Veteran and his spouse testified before the undersigned Veterans Law Judge. A copy of the transcript has been associated with the claims file. In July 2018, the Board remanded the appeal for additional development. The case has now been returned to the Board for further appellate action. Turning to the relevant laws and regulations, service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (1) the existence of a present disability; (2) 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 in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a presumptive basis for diseases listed in 38 C.F.R. § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307. GI Disorder Turning to the evidence, the Veteran was diagnosed with diverticulosis at a June 2019 VA examination. Therefore, a current diagnosis has been shown and the first element of service connection has been met. As to an in-service incurrence, in December 1982, the Veteran complained of mid-abdominal pain, reported a history of burning and abdominal pain and was diagnosed with gastritis. There was no further follow-up. The May 1984 separation examination was negative for complaints of, treatment for, or a diagnosis of diverticulosis and reflected that the GI system was clinically abnormal. Nonetheless, as GI symptoms were noted during service, the second element of service connection has been met. As to nexus, in multiple medical treatment notes since July 2008, medical providers identified an over 30-year history of abdominal pain and bloating; however, the clinicians indicated that the etiology of the Veteran’s abdominal pain was unclear, suggesting that it may have been the result of NSAID use, irritable bowel syndrome, and bacterial outgrowth. Ultimately, the medical providers offered neither a nexus between the Veteran’s service and diverticulosis nor a definitive etiology for his abdominal pain. In a June 2019 VA examination, the examiner diagnosed diverticulosis and identified its onset date as November 2009, the date of a CT scan of the abdomen that revealed diverticulosis without diverticulitis. The examiner opined that it was less likely than not that diverticulosis began in or was otherwise related to service, to include as due to an in-service large intestine condition. The examiner reasoned that there was no diverticular diagnosis on the separation examination and no signs or symptoms in the STRs that revealed that the disorder initially manifested in service. The examiner further found no known correlation in medical literature between diverticulosis and beetle stings as asserted by the Veteran. The examiner further opined that diverticulosis would not be the result of the Veteran’s in-service treatment for gastritis, as the two conditions were separate and independent diagnoses. The Board finds the June 2019 examination to be adequate because the examiner thoroughly reviewed the claims file and addressed the evidence of record to include whether there was nexus between diverticulosis and service, considered the Veteran’s assertions, and provided a thorough supporting rationale for the conclusions reached. As such, the examination is assigned high probative value and weighs against the claim. There is no contradictory medical opinion. Therefore, the medical evidence does not support service connection. As to the lay evidence, the Veteran asserted in March 2018 testimony that he experienced multiple GI problems and described being stung by a beetle and having something “messed up” while serving in Okinawa. He has further cited excerpts from medical articles that stated that many people diagnosed with diverticulosis were initially unaware that they had the condition. He ultimately offered that his in-service abdominal pain reflected his diverticulosis. He is competent to report symptomatology but is not competent to diagnose or opine as to the etiology of his GI disorder. In addition, the VA examiner specifically considered the Veteran’s statements as to a connection between gastritis and/or a beetle bite and rejected a causal relationship between those and the current diagnosis of diverticulosis. As such, while his March 2018 testimony and subsequent November 2020 statement weigh in favor of the claim, they are assigned lesser probative value. Kidney Disorder Kidney disorders are considered to be chronic under 38 C.F.R. § 3.309(a); as such, presumptive service connection on the basis of chronicity/continuity of symptomatology will be considered. Direct service connection will also be discussed. Turning first to direct service connection, the Veteran has been diagnosed with a kidney disorder. Specifically, a June 2019 VA examination diagnosed congenital and polycystic kidney disorders. Therefore, a current diagnosis has been shown and the first element of service connection has been met. As to an in-service incurrence, a review of the STRs are absent of complaints of, treatment for, or a diagnosis of a kidney disorder or any symptoms reasonably associated with a kidney disorder. The Veteran’s genitourinary and endocrine systems were clinically normal in multiple Reports of Medical Examination. The May 1984 separation examination did not diagnose or otherwise identify a kidney disorder. At the March 2018 hearing, the Veteran testified that he constantly had blood in his urine that delayed his in-service deployment to Okinawa. He said that tests were run revealing a G6PD deficiency. [Parenthetically, G6PD is a genetic disorder that leads to break down of red blood cells prematurely.] He asserted that his test results reflected a kidney abnormality; however, while the STRs establish a G6PD deficiency, they do not reflect a diagnosis of a kidney disorder. Rather, the STRs are silent for complaints, diagnoses, or treatment of a kidney disorder or any symptoms reasonably attributed to it. Therefore, the second element of direct service connection – an in-service incurrence – has not been met and the medical evidence does not support service connection on a direct basis. Turning to presumptive service connection based on chronicity and continuity, a May 2006 imaging report identified a cyst within the anterior hilar lip of the Veteran’s left kidney and additional scattered hyperdensities bilaterally that were deemed to likely also represent cysts. The June 2019 VA examination reflects that he was diagnosed with a polycystic kidney disorder in March 2009 and a congenital kidney disorder in June 2019. Even assuming that he developed symptoms of a kidney disorder as early as May 2006, this is outside the one-year presumption period and not shown to a compensable rating within one year of discharge. Next, the record does not establish continuity of symptomatology for a kidney disorder under 38 C.F.R.§ 3.309(a). As noted above, the evidence shows that the Veteran’s kidney disorder began, at the earliest, in May 2006 – more than 20 years after separation from service. Therefore, a kidney disorder was not shown until May 2006, with documentation beginning at the same time. In light of the above, the medical evidence weighs against presumptive service connection based on chronicity or continuity of symptomatology. The Board has considered medical article excerpts submitted by the Veteran concerning G6PD. Treatise evidence may suffice to establish nexus in instances where “standing alone, [it] discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion.” Sacks v. West, 11 Vet. App. 314, 317 (1998). Significantly however, treatise materials generally are not specific enough to show nexus, id. at 317, and that medical opinions directed at specific patients generally are more probative than medical treatises. Herlehy v. Brown, 4 Vet. App. 122, 123 (1993). In this situation, the STRs are absent of complaints related to a kidney disorder and the June 2019 VA examination reflected that the Veteran was not diagnosed with a kidney disorder until 2006, at the earliest, more than two decades after discharge. Further, while medical treatise evidence can provide important support when combined with an opinion of a medical professional, such a medical nexus has not been provided. Mattern v. West, 12 Vet. App. 222, 228 (1999). Rather, the article discusses the definition of a G6PD deficiency, symptoms, causes, and treatment but offered no indication of how it might be related to congenital and polycystic kidney disorders. While not disposition as it relates to this issue, the article suggests that G6PD is a genetic defect, which would not be subject to compensation for VA purposes. As such, this evidence is not dispositive, is assigned lesser probative value, and does not outweigh the findings of the STRs and other medical evidence which was based on the specifics of this Veteran. The Board has also considered the lay statements and testimony submitted by the Veteran and his family regarding the etiology of the disabilities discussed above. Lay witnesses are competent to report symptoms and describe their observations because this requires only personal knowledge as it comes to them through their senses. However, they are not competent to offer an opinion as to the etiology of any current disorder due to the medical complexity of the matters involved. As noted, such competent evidence has been provided by the medical personnel who have examined the Veteran during his current appeal and by service and medical records obtained and associated with the claims file. Here, the Board attaches greater probative value to the clinical findings than to the lay statements and testimony that have been submitted. Based on the above, the appeals are denied. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record for the Board’s consideration. See Doucette v. Shulkin, 28 Vet. App. 366 (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). REASONS FOR REMAND In a November 2020 statement, the Veteran asserted that hypertension was secondary to service-connected posttraumatic stress disorder (PTSD). The most recent examination in June 2019 did not offer an opinion as to a potential causal link between the disorders. In light of the claim that hypertension was caused or aggravated by a service-connected disability, a remand is necessary to obtain a medical opinion as to the etiology of hypertension. The matter is REMANDED for the following actions: 1. Identify and obtain any pertinent, outstanding VA and private treatment records not already of record and associate them with the claims file. 2. Direct the claims file to a clinician for an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran’s hypertension was caused or aggravated by service-connected PTSD. In forming the opinion, the examiner is asked to consider the Veteran’s November 2020 statement alleging a causal relationship between hypertension and PTSD. A rationale for all opinions must be provided. 3. If the clinician determines that an examination is necessary in order to provide the requested opinions, then one should be scheduled. L. HOWELL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Spigelman, 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.