Citation Nr: A21016306 Decision Date: 10/04/21 Archive Date: 10/04/21 DOCKET NO. 190402-2823 DATE: October 4, 2021 ORDER Entitlement to service connection for cardiomyopathy is granted. FINDING OF FACT The Veteran's cardiomyopathy is proximately due to his service-connected asthma/chronic obstructive pulmonary disease (COPD) and hypertension with left bundle branch block. CONCLUSION OF LAW The criteria for service connection for cardiomyopathy as secondary to a service-connected disease or injury are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1977 to May 1997. A rating decision was issued under the legacy system in September 2017. In March 2018, the Veteran filed a timely notice of disagreement and elected a decision review officer. In May 2018, the Veteran filed a RAMP opt-in and selected higher-level review. A July 2018 rating decision was issued. In the April 2019 VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected a Hearing with a Veterans Law Judge. Therefore, the Board may only consider the evidence of record at the time of the RAMP opt-in, as well as any evidence submitted by the Veteran or his representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). The Veteran testified before the undersigned Veterans Law Judge during a June 2021 virtual hearing. A transcript of that proceeding is associated with the claims file. Evidence was not submitted by the Veteran or his representative at the hearing or within 90 days following the hearing. Service connection laws and regulations Entitlement to service connection on a direct basis requires (1) evidence of current nonservice-connected disability; (2) evidence of in-service incurrence or aggravation of disease or injury; and (3) evidence of a nexus between the in-service disease or injury and the current nonservice-connected disability. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Saunders v. Wilkie, 886 F.3d 1356 (2018). Service connection on a secondary basis requires (1) evidence of a current nonservice-connected disability; (2) evidence of a service-connected disability; and (3) evidence establishing that the service-connected disability caused or aggravated the current nonservice-connected disability. 38 C.F.R. § 3.310. After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C. § 7104(a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. A VA claimant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), Gilbert at 54. Entitlement to service connection for cardiomyopathy The Veteran contends that his cardiomyopathy is secondary to his service-connected disabilities. See March 2018 Notice of Disagreement. The RO made the following favorable finding in the July 2018 rating decision: the record confirms a current diagnosis of cardiomyopathy. The Board is bound by favorable findings made by the RO. 38 C.F.R. § 3.104(c). Turning to the evidence, service treatment records reveal no complaints, treatments, or diagnoses pertinent to cardiomyopathy. A February 1998 rating decision granted service connection for asthma/COPD, and service connection for hypertension with left bundle branch block. In a July 2017 private opinion from Dr. P.M., it was opined that the Veteran's dilated cardiomyopathy is related to a combination of factors including underlying coronary artery disease, left bundle branch block, hypertension, diabetes, obesity, and prior history of smoking. In August 2017 the Veteran underwent a VA heart conditions examination. The examination report noted review of the VA e-folder and medical records, recounted the Veteran's complaints and history, and included an in-person examination. The examiner opined that the Veteran's cardiomyopathy is less likely than not proximately due to or the result of the Veteran's service connected asthma/COPD or hypertension with left bundle branch block. The rationale was that although Dr. P.M. provided evidence of the hypertension with left bundle branch block as being an underlying cause, the VA examiner found that other factors, to include obesity with previous lap band surgery, COPD, tobacco abuse, diabetes, and hyperlipidemia were more prevalent supports of the cardiomyopathy. In an August 2017 addendum opinion, the VA examiner clarified that it is less likely than not that the Veteran's cardiomyopathy is proximately due to or the result of asthma/ COPD or hypertension with left bundle branch block, and instead the cardiomyopathy is most likely secondary to obesity, tobacco abuse, diabetes, and hyperlipidemia. In September 2017, the Veteran submitted a private opinion from his primary care manager Dr. V.F. The opinion reviewed the December 2015 evaluation by cardiologist, Dr. T.D., who stated that the Veteran's hypertension with left bundle branch block could be the sole cause of his ischemic cardiomyopathy. Additionally, the opinion reviewed the July 2016 evaluation by Dr. P.M. who stated the Veteran's congestive heart failure, chronic lung disease, and history of myocardial infarction are contributing factors to his ischemic cardiomyopathy. Dr. V.F. also cited medical literature that supports the premise that COPD is a known and accepted cause of cardiopulmonary disease including cardiomyopathy. Moreover, Dr. V.F. stated that coronary artery disease, which is also evident from the Veteran's history of myocardial infarction, can also develop from COPD as a result of increased, systemic, inflammatory response. Based on this review, Dr. V.F. opined that is at least as likely as not that the Veteran's cardiomyopathy was caused by his COPD and hypertension with left bundle branch block following his myocardial infarction from his coronary artery disease. The Board finds that the evidence is at least in equipoise as to whether the Veteran's cardiomyopathy is related to his service-connected conditions, to include as secondary to asthma/COPD, and hypertension with left bundle branch block. While there are conflicting medical opinions, it is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993). The Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). Here, the August 2017 VA examiner's opinion provided a negative nexus as to proximate causation, but it did not address the theory of aggravation. The Board finds the examination and addendum opinion to be inadequate for adjudicative purposes, as the examiner failed to address the aggravation prong of a secondary service connection claim. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (where the VA provides the veteran with an examination in a service connection claim, such examination must be adequate). Therefore, the Board finds the opinions provided neither persuasive nor probative. The Board is most persuaded by the September 2017 positive nexus opinion from Dr. V.F. opining that cardiomyopathy is secondary to the Veteran's service-connected conditions. The opinion appears to be supported by the evidentiary record and based on accepted medical research linking cardiomyopathy to COPD and hypertension with left bundle branch block. The Board finds that the medical opinion is adequate as it is informed by the Veteran's primary care manager (physician), evaluations from Dr. T.D. and Dr. P.M., the Veteran's statements, and the Veteran's post-service treatment records. The examiner provided a discussion of the pertinent evidence and medical principals. As such, in cases such as this when there is an approximate balance of positive and negative evidence the Board must resolve reasonable doubt in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. Accordingly, the Board finds that the evidence is at least in equipoise as to whether cardiomyopathy is related to asthma/COPD, and hypertension with left brach bundle block. Hence the benefit of the doubt rule applies. Id. Therefore, the Veteran's claim for entitlement to service connection for cardiomyopathy, to include as secondary to his service-connected conditions, is granted. As the full benefit of service connection is being granted on the basis of secondary service connection, there is no need to discuss entitlement to service connection on a direct basis or presumptive basis, as other theories of service connection have been rendered moot, leaving no question of law or fact to decide. See 38 U.S.C. § 7104. [SIGNATURE ON NEXT PAGE] JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.M. Edwards, 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.