Citation Nr: 21073512 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 16-00 157A DATE: December 8, 2021 REMANDED Service connection for a gastroesophageal disability, to include gastroesophageal reflux disease (GERD) and Barrett's esophagus, to include as secondary to service-connected CAD, hypertension, and/or posttraumatic stress disorder (PTSD), is remanded. Service connection for erectile dysfunction (ED), to include as secondary to service-connected hypertension, PTSD, and/or CAD, is remanded. Special monthly compensation (SMC) based on loss of a use of a creative organ is remanded. Service connection for a heart disability, other than the service-connected coronary artery disease (CAD), to include paroxysmal atrial fibrillation (PAF) and as secondary to service-connected hypertension, and as secondary to presumed in-service exposure to Agent Orange, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from January 1968 to March 1971. This matter is before the Board of Veterans' Appeals (the Board) on appeal from the June 2015 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. The rating decision, inter alia, denied service connection for acid reflux, service connection for ED, service connection for paroxysmal atrial fibrillation, and entitlement to SMC based on loss of use. The Veteran's Notice of Disagreement (NOD) was received in October 2015. The Statement of the Case was issued in March 2017, and the Veteran's VA Form 9, substantive appeal to the Board, was received in April 2017. The appeal was remanded by the Board in October 2018, June 2020, and March 2021 for further development. 1. Entitlement to service connection for a gastroesophageal disability, to include GERD and Barrett's esophagus, to include as secondary to service-connected CAD, hypertension, and/or PTSD is remanded. In his September 2014 statement, the Veteran indicated that he is entitled to service connection for GERD on a direct basis, as well as secondary to his service-connected PTSD. With respect to claim of service connection on a direct basis, the Veteran has contended that he developed several specific symptoms in service, which were not documented in his STRs, but led to an eventual diagnosis of GERD and Barrett's esophagus. As these contentions have yet to be addressed by a VA medical opinion, they are outlined and underlined below. In his April 2017 VA Form 9, the Veteran contended that he was diagnosed with acid reflux, and that certain stressful life events have been associated with onset or exacerbation of digestive symptoms, including reflux. The Veteran also contended that stress led to amplification of heartburn symptoms, and that there is increasing evidence that psychological treatments, including antidepressants are helpful in reducing reflux symptoms. Additionally, the Veteran indicated that his heart medications cause acid reflux, and that side effects of Metoprolol include heartburn, nausea, and gastric pain. In an October 2020 statement, the Veteran indicated that his PTSD contributed to creating GERD and Barrett's esophagus, along with the infantry food that was given to him in service. Here, the Veteran contended that he was given canned food in service which caused indigestion and upset stomach, which has only gotten worse over the years, leading to a diagnosis of GERD. In November 2019, the Veteran underwent a VA examination for his claim. The VA examiner noted at 2015 diagnosis for GERD. The Veteran reported developing a nighttime cough, pyrosis, regurgitation, and epigastric discomfort approximately 20 years ago and ultimately being diagnosed with GERD and Barrett's esophagus approximately 4 years ago. The Veteran reported daily symptoms and using continuous medication. His symptoms were listed as sleep disturbance caused by esophageal reflux, 4 or more times per year, with average duration of less than 1 day. There was no esophageal stricture, spasm of esophagus, or an acquired diverticulum. The VA examiner concluded that the Veteran's GERD is not related to service because it was not diagnosed until many years after separation. The VA examiner also concluded that GERD is not secondary to, nor aggravated beyond its natural progression by the Veteran's service-connected disabilities because there is no consensus in the medical literature or community that there is a causative or aggravating relationship between these conditions. The VA examiner indicated that GERD is caused by the dysfunction of the lower esophageal sphincter, and that there is no relationship between a malfunctioning lower esophageal sphincter and the Veteran's service-connected disabilities. The June 2020 Board remand found that this opinion improperly relied solely on medical literature without discussing the facts of the Veteran's case or the medical articles submitted by the Veteran and did not discuss Barrett's esophagus. In a September 2020 opinion, a VA examiner concluded that it is less likely than not that the Veteran's GERD and/or Barrett's esophagus is due to the Veteran's CAD, hypertension, and PTSD. The VA examiner cited a Mayo clinic article indicating that GERD is caused by frequent acid reflux, and that risk factors for GERD are obesity, hiatal hernia, pregnancy, smoking, dry mouth, asthma, diabetes mellitus, delayed stomach emptying, and connective tissue disorders such as scleroderma. The VA examiner noted that the exact cause for Barrett's esophagus is not known, but that associated risk factors are GERD, smoking, male sex, white race, and being older. The VA examiner indicated that there is no evidence that use of nonsteroidal anti-inflammatory drugs (NSAIDs) causes Barrett's esophagus. The VA examiner noted that GERD is accepted as the primary etiologic factor for Barrett's esophagus. The VA examiner also indicated that there are instances where an individual may have GERD along with CAD and/or hypertension, but there is no current medical literature that recognizes CAD or hypertension as risk factors for GERD or Barrett's esophagus. The March 2021 Board remand found that the September 2020 VA addendum medical opinion did not address the theory of direct service connection. In April 2021, the Veteran underwent a VA examination. The VA examiner indicated that the Veteran was never diagnosed with an intestinal condition. The VA examiner listed a September 2015 GERD diagnosis, a March 2017 hernia diagnosis, and a March 2017 Barrett's esophagus diagnosis. The Veteran reported symptoms including nighttime cough, heartburn, reflux, indigestion, and regurgitation that started around 20 years ago and were initially treated with tums and diagnosed as GERD in 2015. Under current symptoms, the Veteran was noted to have daily heartburn, reflux, indigestion and nightly regurgitation affecting sleep. It was noted that the Veteran required daily continuous medication, and that his symptoms were productive of considerable impairment of health, infrequent episodes of epigastric distress, pyrosis, reflux, regurgitation, substernal pain, and sleep disturbance. The March 2017 upper endoscopy was cited as confirming presence of a hernia and Barrett's esophagus. The VA examiner concluded that the Veteran's esophageal conditions did not impact his ability to work. After a thorough review of the Veteran's records, the VA examiner concluded that it is less likely than not that the Veteran's GERD and Barrett's esophagus were incurred in, or caused by the Veteran's service, to include presumed exposure to Agent Orange. The VA examiner indicated that the disability does not meet the criteria for presumptive exposure and was not incurred in service. The VA examiner also indicated that the Veteran's GERD and Barrett's esophagus were not secondary to, or aggravated by his service-connected Hepatitis C, tinnitus, radiculopathy, PTSD, bilateral hearing loss, back disability, hypertension, kidney disability, lumbar scar, and CAD. The VA examiner indicated that there is neither a consensus of evidence in the medical literature or in the medical community that supports a causative or aggravating relationship between GERD and the Veteran's service-connected disabilities, noting that GERD is caused by a dysfunction of the lower esophagus sphincter and Barrett's esophagus is caused by the damage of the lower esophagus. The VA examiner also indicated that Barrett's esophagus is usually the result of repeated exposure to stomach acid, noting that there is no relationship between GERD and/or Barrett's esophagus and the Veteran's service-connected disabilities. Finally, the VA examiner noted that GERD and Barrett's esophagus are separate entirely from, and unrelated to, the Veteran's service-connected disabilities, and that a thorough review of medical literature failed to demonstrate a causal relationship. Despite this lengthy record, an adequate medical opinion addressing the Veteran's reported symptoms, irrespective of whether they were documented in his STRs, has not been obtained. As underlined above, an October 2020 statement from the Veteran indicates that he was given canned food in service which caused indigestion and upset stomach, which has only gotten worse over the years; the November 2019 VA examination report indicates that the Veteran reported developing a nighttime cough, pyrosis, regurgitation, and epigastric discomfort approximately 20 years ago; and, the April 2021 VA examination report indicates that the Veteran reported developing nighttime cough, heartburn, reflux, indigestion, and regurgitation around 20 years ago. To date, no VA opinion has addressed whether these reported symptoms, irrespective of being documented in the Veteran's STRs, along with the Veteran's eventual diagnosis of Barrett's esophagus, make it as likely as not (a 50 percent probability or more), that the Veteran's GERD and Barrett's esophagus is related to his service. Notably, the April 2021 VA medical opinion is inadequate to the extent that it does not contain a rationale for concluding that the Veteran's GERD is not related to presumed exposure to Agent Orange. Specifically, the April 2021 VA examiner states only that the Veteran's GERD and Barrett's esophagus did not meet the criteria for Agent Orange. With respect to Agent Orange, service connection is presumed for certain diseases if a veteran is exposed to an herbicide agent, such as Agent Orange, during active service. 38 U.S.C. § 1116; 38 C.F.R. § 3.307. GERD and Barrett's esophagus are not among the disabilities listed. However, service connection on a direct basis is not precluded merely because the disease is not one of those enumerated under 3.307(e). In other words, a disease need not be presumed due to Agent Orange exposure to warrant service connection; however, there must still be a nexus between the in-service injury (Agent Orange exposure in this case) and the current GERD and Barrett's esophagus. Combee v. Brown, 34 F. 3d 1039, 1043-1044 (Fed. Cir. 1994). In essence, the mere absence of the disability on the presumptive list, alone, is not an adequate basis for denial of service connection. Accordingly, a remand is necessary to obtain an opinion determine whether Veteran's reported in-service symptoms along with eventual diagnosis of Barrett's esophagus make it at least as likely as not that the Veteran's GERD and Barrett's esophagus had their onset in service, or were otherwise causally related to service, to include exposure to Agent Orange, as the April 2021 opinion flawed. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213, 216 (1992). 2. Entitlement to service connection for ED, to include as secondary to service-connected hypertension, PTSD, and/or CAD is remanded. In his September 2014 statement, the Veteran contends that he is entitled to service connection for ED on a direct basis, as well as on secondary his service-connected PTSD, as well as due to any medications that he is taking for any service-connected disability. In his April 2017 VA Form 9, the Veteran contended that he takes Metoprolol, which induces his ED. He also indicated that sexual dysfunction is prevalent in Veteran's with PTSD, as noted in cited medical literature. In November 2019, the Veteran underwent a VA examination for his claim. The Veteran reported difficulty maintaining erections approximately 15 years ago and ultimately being diagnosed with ED. He was noted to be taking medication. There was no voiding dysfunction. The VA examiner confirmed the diagnosis of ED and concluded that the Veteran's ED is not secondary to, or aggravated beyond its natural progression by his service-connected conditions. The VA examiner indicated that there is neither a consensus of evidence in the medical literature or in the medical community that supports a causative or aggravating relationship between these conditions. The VA examiner also indicated that ED is caused by vascular, neurologic, hormonal, and psychological systems. The VA examiner noted that the Veteran reported ED 15 years ago and was diagnosed 3 years ago, and that although PTSD is a risk factor, there is no consensus in the medical field that it is singularly causative or aggravating. The VA examiner stated that essentially, ED is a multifactorial in origin, and the Veteran has several risk factors for developing it. The VA examiner concluded that it would be impossible to attribute one risk factor in the Veteran's case as being causative or aggravating unless the factor was overwhelmingly associated, which was not the case. The VA examiner also concluded that ED was not related to service, as the Veteran was not diagnosed until many years after separation. The June 2020 Board remand found that this opinion is not adequate as it relied solely on medical literature without discussing the specific background of the Veteran's case, other than to say ED began 15 years ago, improperly implied that the Veteran's service-connected disability must be the sole cause of ED and did not discuss the Veteran's medications. In a September 2020 VA opinion, a VA examiner concluded that the Veteran's ED was less likely than not proximately due to, or the result of his PTSD. The VA examiner noted that the Veteran was prescribed Sildenafil for his ED in April 2004, and that the time he had Hepatitis C and chronic low back pain. It was also noted that he was not drinking alcohol at the time. The VA examiner indicated that the Veteran was 56 at the time and did not have PTSD, CAD, or hypertension. The VA examiner noted hypertension being diagnosed in September 2011 and CAD being noted in November 2009. The VA examiner listed risk factors for ED as age, medications, hypertension, obesity, DM, hyperlipidemia, smoking, and psychogenic factors, providing percentage prevalence for these factors, and citing relevant medical literature. The VA examiner also provided studies outlining these risk factors. The VA examiner then stated that in April 2004, the first time the Veteran was noted to have ED, he did not have hypertension, CAD, and was not actively drinking alcohol. The VA examiner concluded that given that these disabilities were not present at the time, they could not have contributed to ED. The VA examiner also concluded that it is more likely that the Veteran's age, 56 was the contributing factor for ED. The VA examiner also concluded that it is less likely than not that the Veteran's ED is due to his CAD, hypertension, with the same rationale as above. With respect to aggravation, the VA examiner concluded that it is less likely than not that the Veteran's ED is aggravated beyond its natural progression by his service-connected PTSD, CAD, and hypertension. The VA examiner noted that the November 2019 VA examination report indicated that the Veteran's ED was treated with Cialis, but not effective, that he did not have orchiectomy, that there was no associated renal dysfunction, no retrograde ejaculation, no male reproductive infections, no associated tumors or neoplasms, no scars, not other pertinent physical findings, complications, conditions, signs or symptoms related to ED, and it did not impact the Veteran's ability to work. Then, the VA examiner noted that medical literature supports the finding that the Veteran's ED is associated with natural aging, and therefore could not be aggravated by PTSD, CAD, and hypertension. With respect to the Veteran's medications, the VA examiner listed the medications the Veteran was prescribed, including Metoprolol, Amlodipine, Pravastatin, Melatonin, Tramadol, Isosorbide Mononitrate, and Trazodone. The VA examiner then listed the percentage statistics for each medication, citing appropriate medical literature. Each medication was listed as having less than 1 percent of users reporting ED. The VA examiner concluded that while the Veteran was on several medications for his service-connected disabilities, the actual number of individuals developing ED from these medications would definitely be lower than 50 percent. The VA examiner also noted that there is no indication of the Veteran's ED being aggravated, showing that these medications did not aggravate the Veteran's ED. The VA examiner addressed the articles the Veteran submitted, and indicated that actual statistics of ED occurring as a result of taking the medications for his service-connected disabilities are low and certainly less than 50 percent. The VA examiner also addressed the notation in the Veteran's VA treatment records indicating that ED is due to his general medical condition, indicating that at the time of being diagnosed with ED, he did not have PTSD, hypertension, CAD, or atrial fibrillation. The VA examiner concluded that therefore, the Veteran's overall general medical condition was not so dilapidated as to result in ED. The March 2021 Board remand found that the September 2020 VA addendum medical opinion did not address the theory of direct service connection. In April 2021, the Veteran underwent a VA examination. A May 2014 diagnosis of ED was noted. Given the totality of the evidence of the record, it is clear that this is a typographical error, and the Veteran was diagnosed with ED approximately in May 2004. The Veteran reported onset of ED in 2004, at which point he was diagnosed and prescribed medication. It was noted that he believed getting Viagra in 2014. The VA examiner noted that the Veteran's VA records show ED in May 2014. The Veteran reported that he is unable to achieve an erection without medication and that 99 percent of the time he is unable to maintain the erection. It was noted that the Veteran was prescribed Viagra (Sildenafil). There was no orchiectomy, no renal dysfunction, no voiding dysfunction, no retrograde ejaculation, and no history of chronic epididymitis. Under etiology of ED, the VA examiner noted "unsure most likely 'age related'". Physical examination was normal. There were no tumors or neoplasms. The VA examiner concluded that the Veteran's ED did not impact the Veteran's ability to work. After thoroughly summarizing the evidence, the VA examiner concluded that it is less likely than not that the Veteran's ED was incurred in, or caused by service. The VA examiner indicated the Veteran's ED did not have its onset in service and was not diagnosed until 2004. The VA examiner also noted that the Veteran is taking medication as needed, and denied surgical intervention or prostate issues. The VA examiner also indicated that they are unable to confirm a current chronic diagnosis of ED during service, and therefore, no nexus or plausible secondary relationship is established. The VA examiner indicated that medical evidence is not sufficient to support a determination of a baseline level of severity and that it is less likely than not that the Veteran's ED was aggravated beyond its natural progression. For rationale, the VA examiner stated that ED had its onset in 2004 and has not required surgical intervention or caused prostate issues. With respect to Agent Orange, the VA examiner noted that ED does not meet the criteria for presumptive Agent Orange exposure. With respect to secondary service connection, the VA examiner conclude that it is less likely than not that the Veteran's ED is proximately due to, or the result of the Veteran's service-connected hypertension, back scar, hearing loss, kidney disability, tinnitus, radiculopathy, hepatitis C, CAD, back disability, and PTSD. For rationale, it was noted that these disabilities are separate entirely from ED and unrelated to it. The VA examiner also noted that a thorough review of medical literature failed to demonstrate a causal relationship and that a nexus has not been established. With respect to aggravation by a service-connected disability, the VA examiner could not determine the baseline of severity, and concluded that it is less likely than not that ED was aggravated beyond its natural progression by the Veteran's service-connected disabilities. For rationale, the VA examiner indicated that there is neither a consensus of evidence in the medial literature or the medical community that supports a causative or aggravating relationship between the disabilities. It was noted that ED is caused by vascular, neurologic, hormonal, physical, and psychological systems, and that although some of the disabilities are risk factors for ED (hypertension, kidney disability, radiculopathy, hepatitis C, CAD, back disability, and PTSD), there is no consensus in the medical community of these disabilities being singularly causative or aggravating, as ED is multifactorial in origin, and the Veteran has several risk factors, including age. The VA examiner further noted that it would be impossible to attribute one risk factor as being causative or aggravating unless the risk factor was overwhelmingly associated, which is not the case with the Veteran. For disabilities that are not risk factors for ED, (back scar, hearing loss, and tinnitus) the VA examiner noted these are not risk factors, and therefore cannot aggravate ED. Despite this lengthy record, an adequate medical opinion addressing direct service connection and presumptive Agent Orange exposure has not been obtained. In this case, the Veteran contends that he developed ED in 2004 and that it relates to service, including presumed Agent Orange exposure. The April 2021 VA medical report indicates that a nexus is not established because the Veteran was not diagnosed with ED in service. The same medical opinion indicates that ED is not covered under Agent Orange exposure. Thus, the April 2021 VA medical opinion is inadequate to the extent that it solely relies on absence of in-service diagnosis for a negative nexus opinion. Additionally, the April 2021 VA medical opinion is inadequate to the extent that it does not contain a rationale for concluding that the Veteran's ED is not related to presumed exposure to Agent Orange. Specifically, the April 2021 VA examiner states only that the Veteran's ED does not meet the criteria for Agent Orange. As noted above, absence of ED on the list of enumerated disabilities under 38 C.F.R. § 3.307(e) does not preclude establishing service connection on a direct basis. Accordingly, the matter is remanded for a VA medical opinion to address the Veteran's claim of service connection for ED. 3. Entitlement to SMC based on loss of use of a creative organ is remanded. The issue of entitlement to SMC based on loss of use of creative organ is inextricably intertwined with the Veteran's claim for service connection for ED, which is being remanded pursuant to this decision. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to remand the claim on appeal pending the adjudication of the inextricably intertwined claim. Harris v. Derwinski, 1 Vet. App. 180 (1991). Thus, the claim for SMC based on loss of use of a creative organ must be remanded. 4. Service connection for a heart disability, other than the service-connected CAD, to include PAF as secondary to service-connected hypertension, and as secondary to presumed in-service exposure to Agent Orange, is remanded. The Veteran seeks service connection for a heart disability, other than his service-connected CAD. Specifically, the Veteran indicates that he was diagnosed with PAF and that it is related to service, to include as due to his exposure to Agent Orange. In the alternative, the Veteran contends that his heart disability, other than CAD, is related to his service-connected disabilities. In March 2021, the Board remanded the appeal to obtain a VA opinion to address whether the Veteran has or had a heart disability, other than CAD, during the appeal period, as the evidence of record contained conflicting opinions. Pursuant to the March 2021 Board remand, a VA opinion in April 2021 was obtained. In the April 2021 VA examination report, the examiner stated that "[r]eview of the C-File and today's C&P Exam (04/13/2021) shows the Veteran has (and/or 'has had') THREE (3) Heart Related Conditions." Thereafter, the April 2021 VA examiner list atrial fibrillation/PAF, as one of the three heart related conditions. The April 2021 VA examiner concluded that he was "[u]nable to confirm a current chronic diagnosis of [PAF] with current available records and/or today's exam. Therefore, [n]o nexus or plausible secondary relationship is established." The April 2021 VA opinion is flawed, as the examiner's opinion is internally inconsistent. Accordingly, a remand is necessary to obtain an adequate opinion regarding the Veteran's claim of service connection for a heart disability, other than CAD. The matters are REMANDED for the following action: 1. Obtain an addendum VA medical opinion as to the nature and etiology of the Veteran's GERD and Barrett's esophagus. The VA examiner is requested to review all pertinent records associated with the claims file, including copies of all relevant VA examination reports, previous Board remands, and this remand. The VA examiner is requested to opine as to the following: (a.) Whether the Veteran's reported symptoms of indigestion and upset stomach after eating canned food in service, irrespective of being noted in his STRs, along with presence of Barrett's esophagus suggesting prior presence of GERD, make it at least as likely as not (a 50 percent probability or more), that the Veteran's GERD and Barrett's esophagus had their onset in service, or were otherwise causally related to the Veteran's service, including presumed exposure to Agent Orange. (b.) In providing the requested opinion, the clinician should consider the Veteran's reported injury and symptoms in service and thereafter, including the nature of his reported injury and the onset, progression and severity of his reported symptoms. (c.) In providing this opinion, the VA examiner is requested to address the Veteran's October 2020 statement indicating that indigestion and upset stomach after eating canned food in service, continued after service, and only gotten worse over the years; the Veteran's November 2019 VA examination reports of developing a nighttime cough, pyrosis, regurgitation, and epigastric discomfort approximately 20 years ago; and, the Veteran's April 2021 VA examination reports of developing nighttime cough, heartburn, reflux, indigestion, and regurgitation around 20 years ago. The VA examiner is requested to provide a full rationale for all conclusions reached. 2. Obtain an addendum VA medical opinion as to the nature and etiology of the Veteran's ED. The VA examiner is requested to review all pertinent records associated with the claims file, including copies of all relevant VA examination reports, previous Board remands, and this remand. The VA examiner is requested to opine as to the following: (a.) Whether it is at least as likely as not (a 50 percent probability or more) that the Veteran's ED had its onset in service, or was otherwise causally related to service, to include presumed exposure to Agent Orange. In providing this opinion, the VA examiner is requested to provide a full rationale for all conclusions reached. 3. Refer the claims file to a physician for an opinion regarding the Veteran's claim of service connection for a heart disability, other than CAD. After a review of the claims file, the VA physician should identity whether the Veteran has or had a heart disability, other than CAD, even if resolved, at any time during the appeal period which began approximately in September 2014. The physician should opine whether it is at least as likely or not (greater than 50 percent probability) the Veteran's heart disabilities, if any, other than CAD, had its onset in service or caused by his military service, to include as due to his in-service exposure to Agent Orange. The physician should, also, opine as to whether it is at least as likely or not (greater than 50 percent probability) the Veteran's service-connected CAD caused or aggravated his heart disability. The examiner must provide a rationale for each opinion. 4. Following readjudication of the claim for service connection for ED, readjudicate the claim for SMC based on loss of use of creative organ. Ashley Castillo Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Kuksova, Kseniya 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.