Citation Nr: 21068540 Decision Date: 11/10/21 Archive Date: 11/10/21 DOCKET NO. 16-16 940 DATE: November 10, 2021 ORDER Entitlement to service connection for an autoimmune disorder, to include Sjögren's disease, Raynaud's syndrome, scleroderma, lupus, rheumatoid arthritis, and anemia is granted. Entitlement to service connection for an esophageal motility disorder, to include gastroesophageal reflux disease (GERD), to include as secondary to an autoimmune disorder is granted. REMANDED Entitlement to service connection for a tubal ligation, to include as secondary to an autoimmune disorder is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, her autoimmune disorders began during active service. 2. The Veteran's esophageal motility disorder is proximately due to her service-connected autoimmune disorders. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for an autoimmune disorder, to include Sjögren's disease, Raynaud's syndrome, scleroderma, lupus, rheumatoid arthritis, and anemia are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for an esophageal motility disorder, to include GERD, as secondary to an autoimmune disorder are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 2003 to April 2004, from December 2004 to February 2005, and from July 27, 2010 to October 30, 2010, with additional service in the Air Force National Guard from November 2002 to October 2012. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2013 rating decision by the Department of Veterans Affairs (VA), Regional Office (RO). The claims were last before the Board in September 2018, March 2021, and July 2021. The matters were remanded for additional development and have since been returned for further appellate review. The Board has expanded the Veteran's claim of service connection for Sjögren's disease with probable scleroderma, esophageal motility disorder with Raynaud's syndrome (autoimmune disorder) as reflected on the title page. See Clemmons v. West, 206 F.3d 1401, 1403 (Fed. Cir. 2000). Duties to Notify and Assist The Veteran has not raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Anemia, lupus, Raynaud's disease, rheumatoid arthritis, and scleroderma are chronic diseases under 38 C.F.R. § 3.309 (a). As such, the presumptive service connection provisions under 38 C.F.R. § 3.303 (b) for service connection based on "chronic" symptoms in service and "continuous" symptoms since service are applicable to that issue. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Under 38 C.F.R. § 3.303 (b), service connection will be presumed where there are either chronic symptoms shown in service or continuity of symptomatology since service for diseases identified as "chronic" in 38 C.F.R. § 3.309 (a). Walker, 708 F.3d at 1338-40 (holding that continuity of symptomatology is an evidentiary tool to aid in the evaluation of whether a chronic disease existed in service or an applicable presumptive period). With a chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303 (b). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The Board has thoroughly reviewed all the evidence in the claims file and adequately addresses the relevant evidence in the instant decision. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, every piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record but does not have to discuss each piece of evidence). 1. Entitlement to service connection for an autoimmune disorder, to include Sjögren's disease, Raynaud's syndrome, scleroderma, lupus, rheumatoid arthritis, and anemia. The Veteran contends that she has an autoimmune disorder that is related to service. The Veteran has current diagnoses of Sjögren's disease, Raynaud's syndrome, scleroderma, anemia, and rheumatoid arthritis as evidenced by June 2013 VA examination reports. She was also diagnosed with systemic lupus erythematosus as evidence by a July 2012 private treatment record. Raynaud's syndrome, scleroderma, lupus, arthritis, and anemia are enumerated conditions under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. Service treatment records dated November 2011, show that the Veteran was diagnosed with Sjögren's disease in May 2011 and also had a diagnosis of inflammatory polyarthritis. Service treatment records dated December 2011, also note the Veteran was hospitalized for an autoimmune disorder in the previous two months. Prior to July 2010, the Board notes there is no mention in service treatment records of an autoimmune disorder or related symptoms reported by the Veteran. Private treatment records dated as early as June 2011 note the Veteran was diagnosed and treated for lupus. At the June 2013 VA examination, the Veteran reported having symptoms of dryness of her eyes and mouth and joint pains and being diagnosed with Sjögren's disease, and scleroderma in 2010. The examiner opined that her anemia and Raynaud's disease were likely due to her Sjögren's syndrome. At a July 2019 VA examination, the examiner noted the onset of the Veteran's Sjögren's disease with probable scleroderma was in 2011. A September 2019 VA medical opinion notes the Veteran's Sjögren's disease was at least as likely as not related to service. The examiner noted that a 2012 diagnosis confirmed the Veteran had Sjögren's disease and that she complained of associated symptoms prior to that time, and it was likely that the disorder began during her active-duty period of service. After review of the evidence in its entirety, the Board will resolve reasonable doubt in the Veteran's favor and find that she has an autoimmune disorder that had its onset during her period of active-duty service and continued with no intercurrent causes since service separation. As noted above, the Veteran has several autoimmune disorders that are considered chronic conditions under 38 C.F.R. § 3.309(a) and the evidence suggests that these disabilities are all related to the Veteran's Sjögren's disease. The evidence of record shows that the Veteran's Sjögren's disease initially manifested during her period of active service and has continued since service. Therefore, the Board finds that the Veteran has an autoimmune disorder that had its onset in service and has continued with no intercurrent causes. 2. Entitlement to service connection for an esophageal motility disorder, to include GERD, to include as secondary to an autoimmune disorder. The Veteran contends that she has an esophageal disability that his related to service or in the alternative to her service-connected autoimmune disorder. The June 2013 VA examination report shows the Veteran has a current diagnosis of GERD likely from the esophageal involvement of her scleroderma. Additionally, a February 2012 private treatment record suggest there is an association between the Veteran's Sjögren's disease and GERD. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for an esophageal motility disorder is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND Entitlement to service connection for a tubal ligation, to include as secondary to an autoimmune disorder is remanded. Here, the Veteran has asserted that she underwent a tubal ligation due to her autoimmune disorder. Per this decision, the Veteran is in receipt of service connection for an autoimmune disorder. Thus, remand is required to obtain an adequate medical opinion on the Veteran's claim on a secondary basis. The record contains a September 2021 VA medical opinion, however, the examiner failed to provide an opinion of the Veteran's claim on a secondary basis. The matter is REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's tubal ligation is at least as likely as not proximately due to service-connected disability or aggravated beyond its natural progression by service-connected disability. The relevant facts and medical history should be made available to the clinician. A rationale for the opinion and a discussion of the facts and medical principles involved should be provided. The examiner must review the entire record in conjunction with making the requested opinion. IN ADDITION TO ANY RECORDS THAT ARE GENERATED BECAUSE OF THIS REMAND, the VA examiner's attention is drawn to the following: *October 2011, a private treatment record notes the Veteran had bilateral tubal ligation surgery. The record also notes the Veteran had a diagnosis of lupus. *August 2012, a private treatment record notes the Veteran had a tubal ligation on October 2011 to avoid future high-risk pregnancies. The physician also noted the Veteran had lupus. *Service connection is effect for autoimmune disorders to include Sjögren's disease, Raynaud's syndrome, scleroderma, lupus, rheumatoid arthritis, and anemia. 2. After completing the requested action, and any additional actions considered warranted, readjudicate the claim on appeal. If the benefit sought on appeal remains denied, the Veteran should be given a supplemental statement of the case and given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. K.A. KENNERLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. McDuffie, 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.