Citation Nr: 21073551 Decision Date: 12/09/21 Archive Date: 12/09/21 DOCKET NO. 17-39 885A DATE: December 9, 2021 ORDER Entitlement to service connection for migraine headaches is granted. Entitlement to service connection for major depressive disorder is granted. Entitlement to service connection for coronary heart disease (CAD), to include coronary arteriosclerosis is granted. Entitlement to service connection for peripheral vascular disease (PVD) of the right lower extremity is granted Entitlement to service connection for PVD of the left lower extremity is granted. Entitlement to service connection for right lower extremity neuropathy is granted. Entitlement to service connection for right upper extremity neuropathy is granted. REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for left upper extremity neuropathy is remanded. Entitlement to service connection left lower extremity neuropathy is remanded. FINDINGS OF FACT 1. The Veteran's headaches are caused by his service-connected tinnitus. 2. The Veteran's major depressive disorder began in-service and his aggravated by his multiple service connected disabilities. 3. The Veteran's major depressive disorder aggravated the Veteran's CAD, with coronary arteriosclerosis. 4. The Veteran's CAD, coronary arteriosclerosis was caused by the Veteran's PVD of the left lower extremity. 5. The Veteran's CAD, coronary arteriosclerosis was caused by the Veteran's PVD of the right lower extremity. 6. The Veteran's right lower extremity neuropathy was caused by the Veteran's PVD. 7. The Veteran's right upper extremity neuropathy was caused by the Veteran's PVD. CONCLUSIONS OF LAW 1. The criteria for service connection for migraine headaches as secondary to tinnitus are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for entitlement to service connection for major depressive disorder have been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for CAD, with coronary arteriosclerosis as secondary to major depressive disorder are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for service connection for PVD of the left lower extremity as secondary to CAD, with coronary arteriosclerosis disorder are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 5. The criteria for service connection for PVD of the right lower extremity as secondary to CAD, with coronary arteriosclerosis disorder are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 6. The criteria for service connection for neuropathy of the right lower extremity as secondary to PVD. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 7. The criteria for service connection for neuropathy of the right upper extremity as secondary to PVD. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1972 to September 1976. This matter comes before the Board of Veterans' Appeals (Board) from a decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Board previously this matter in April 2019. A claim for service connection for a disability may encompass claims for service connection of any disability that may reasonably be encompassed by several factors, including the claimant's description of the claim, the symptoms the claimant describes and the information the claimant submits or that the Secretary obtains in support of the claim. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Accordingly, the Board has taken an expansive view of the Veteran's claim for service connection for a heart condition and mental health condition pursuant to Clemons. Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303, 3.304. Service connection generally requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247 (1999). A disability may be service connected on a secondary basis by demonstrating that the disability is either (1) proximately due to or the result of an already service-connected disease or injury, 38 C.F.R. § 3.310 (a) or (2) aggravated by an already service-connected disease or injury, 38 C.F.R. § 3.310 (b). 1. Migraine Headaches The Veteran is seeking service connection for headaches as secondary to his service-connected tinnitus. The Veteran is currently service connected for tinnitus. In January 2021, the Veteran submitted a private examination report signed in April 2017, related to his headaches. The private examiner diagnosed the Veteran with migraine including migraines variants. The examiner opined that it is likely as not the Veteran's migraine headaches are caused by his service-connected tinnitus. The examiner reasoned that it is known that damage to the auditory system resulting in tinnitus can also cause headaches. The Board finds that the pertinent evidence in the record is the April 2017 private examination is probative. Therefore, the Board finds that the probative evidence establishes that the Veteran has a current disability of migraine headaches and they were caused by the Veteran's service-connected tinnitus. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for migraine headaches is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Major Depressive Disorder The Veteran is seeking service connection for a psychiatric disability to include a major depressive disorder, to include as secondary to his service-connected disabilities. The Veteran's service treatment records do not note any psychiatric diagnosis. The service treatment records demonstrated that the Veteran was treated for injuries to his hands from a fist fight. In January 2021, the Veteran submitted a private psychiatric DBQ that was signed in June 2017. The private examiner diagnosed the Veteran with major depressive disorder. The June 2017 private examiner opined that based on an interview with the Veteran, letters from the Veteran's file, and the medical record that the Veteran's depressive disorder started in service. The examiner also determined that the Veteran's multiple health problems aggravate his depressions to including tinnitus, left ear hearing loss, heart problems, leg problems, and headaches. The examiner noted that it was not possible to determine how much each condition contributed to the Veteran's depression. In January 2021, the Veteran submitted a statement from the Veteran's brother signed in September 2017. The Veteran's brother stated that upon separating from service, he noticed that the Veteran had marital problems and was having issues abusing alcohol. The Veteran's brother noted the Veteran was not the same person as he was before service emotionally. The Veteran's brother stated that ever since service the Veteran struggled with emotional problems and used alcohol to cope with those issues. The Veteran's brother stated that the Veteran's service clearly changed him. In January 2021, the Veteran submitted a statement from his sister singed in September 2017. The Veteran's sister stated that the Veteran had no mental health issues prior to service. The Veteran's sister stated that when Veteran left service, she remembered him having a lot of different jobs. She noted that it seemed the Veteran was unable to adjust to work outside the military. The Veteran's sister stated that the Veteran had several marriages that did not work out. She stated the Veteran turned to alcohol to deal with his issues. The Veteran's sister noted that with the help of VA his drinking had gotten better, but over the last three years he seemed to be constantly down and depressed. The Veteran's sister further noted that over the past three years, the Veteran had headaches. She noted that when the Veteran's got his headaches he became short tempered and snappy. The Veteran's sister stated when she inquired about the Veteran's headaches, he would become agitated. The Board finds that the only probative evidence of record, the June 2017 DBQ completed by a private examiner demonstrates that the Veteran's diagnosed major depressive disorder began in-service and is also aggravated by his multiple service connected disabilities. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for major depressive disorder is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Coronary Artery Disease (CAD), Coronary Arteriolosclerosis, and Peripheral Vascular Diseases (PVD) The Veteran contends that his coronary artery disease, coronary arteriolosclerosis, and PVD of the bilateral lower extremities are related to his psychiatric disorder. The Veteran's VA treatment records indicates diagnoses and histories of coronary artery disease (CAD), coronary arteriosclerosis, and PVD of the bilateral lower extremities. In January 2020, the Veteran underwent a series of examinations related to his heart condition and his PVD. In the heart conditions DBQ, the examiner diagnosed the Veteran with CAD. It is noted that in the remarks of the heart conditions DBQ, the examiner in what appears to be a response to the issue of coronary arteriosclerosis, stated "refer to the diagnostic section." The Board infers this statement to indicate the Veteran did not have a diagnosis of coronary arteriosclerosis as the diagnostic section only noted a diagnosis of CAD. The examiner opined that the claimed condition was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that the Veteran's CAD was likely due to his exposure to chemicals in-service. The examiner noted that the Veteran served during the Vietnam era in which he was exposed to chemicals that have been noted to increase the risk of CAD. In the artery and vein conditions DBQ, the examiner diagnosed the Veteran with PVD. The examiner was not clear whether the Veteran's PVD was bilateral, however, the examiner described some symptoms of bilateral PVD. Thus, the Board presumes the January 2020 VA examiner's diagnosis of PVD is for both the lower extremities, despite some indication in the examination that right lower extremity was affected. The examiner opined that the Veteran's PVD is at least as likely as not the result of his CAD as a study document indicates the CAD is a significant risk factor for the development of PVD. The examiner also opined the Veteran's PVD is less likely than not to have been further aggravated by his CAD but more likely due to his continuous smoking as this is a significant risk factor for worsening of PVD. In September 2020, the January 2020 VA examiner provided an addendum medical opinion. The examiner stated that the Veteran's CAD is less likely than not to have been caused by his time in service as there is no correlations linking his time in service to his CAD as he was not exposed the chemicals. In January 2021, the Veteran submitted a private opinion by a private doctor from April 2017. The private doctor diagnosed the Veteran with coronary arteriosclerosis, CAD, and PVD. The private doctor opined that it is as likely as not that the Veteran's depressive disorder aided in the development of and permanently aggravated his coronary arteriosclerosis and coronary artery disease. The examiner reasoned that medical literature states that depression is common in patients with cardiovascular heart disease. The examiner explained the data is consistent in supporting that depression is a risk factor for both the development and worsening of CAD. The examiner noted studies support the fact that depression is an independent risk factor for the development of CAD and its complications. The private doctor further noted that these studies suggest that depression leads to heart disease by causing hypothalamus to release CRF, which in turn increases the level of corticosteroids, which may trigger arteriosclerosis. The private doctor stated that a complication of PVD is characterized by narrowing of the arteries of the lower extremities due to atherosclerosis. The Board finds that the evidence of record indicates that the Veteran's now service-connected major depressive disorder aggravated the Veteran's CAD and coronary arteriosclerosis. The Board relies on the probative evidence of the private April 2017 medical opinion. Further, the Board finds that the Veteran's PVD is secondary to either the Veteran's CAD or coronary arteriosclerosis. The Board notes that the January 2020 VA examiner found the Veteran's PVD was at least as likely as not caused by the Veteran's CAD and the private April 2017 opinion noted the Veteran's coronary arteriosclerosis led to the Veterans PVD. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for CAD, coronary arteriosclerosis, and PVD are warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Neuropathy of the Upper and Lower Right Extremities The Veteran contends that his neuropathy of the upper and lower extremities is related to service or is otherwise secondary to his service-connected disabilities. In January 2020, the Veteran underwent a VA peripheral nerves conditions neuropathy examination. The examiner diagnosed the Veteran with upper and lower right extremity neuropathy. The examiner opined that the Veteran's neuropathy was less likely than not due to the Veteran's CAD. The examiner reasoned that the Veteran's neuropathy was due to the Veteran's PVD. The examiner opined that the Veteran's neuropathy is less likely than not aggravated by its natural progress due to his CAD. The examiner explained that the Veteran's medical provider noted in December 2018 that the peripheral neuropathy was multi-factorial from his previous alcohol abuse, PVD and radiculopathy from spinal stenosis. The Board finds that as the Veteran is now service connection for PVC of the bilateral lower extremities and the January 2020 VA examiner found the Veteran's diagnosed neuropathy of the upper and lower right extremities was caused by his PVD, service connection must be granted. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for lower right extremity and upper right extremity neuropathy is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Hypertension The Veteran contends his hypertension is related to service or in the alternative secondary to his service-connected disabilities. In January 2020, the Veteran underwent a VA examination for hypertension. The examiner diagnosed the Veteran with hypertension. The examiner opined that the claimed condition is less likely than not proximately due to or the result of the Veteran's service-connected condition. The examiner reasoned the Veteran's hypertension is less likely than not caused by CAD as she found the Veteran had high blood pressure at the same time as CAD. The examiner explained that it is likely that his blood pressure contributed to his CAD. The examiner stated without knowing which disease came first she was unable to say definitively if the Veteran's hypertension was due to the CAD. Further, the examiner opined that the Veteran's hypertension was less likely than not to have been aggravated by the natural progression by his CAD as records from December 2018 show controlled blood pressure. The examiner explained the Veteran had been able to maintain his blood pressure with medication. The examiner noted that the examination conducted showed elevated blood pressure because the Veteran had not taken his blood pressure medication. The Board finds the January 2020 VA examiner's opinion is not adequate for adjudication. The January 2020 VA examiner explained that the Veteran's hypertension was not aggravated because it was controlled by medication. Such reasoning is inadequate, notably because the examiner stated that when the Veteran did not take his medication his blood pressure was elevated at the January 2020 examination, which demonstrated evidence of aggravation. The examiner did not address whether the aggravation of his hypertension was caused by his now service-connected disabilities. Thus, upon remand, the examiner must provide an addendum opinion regarding whether the Veteran's hypertension was aggravated due to the Veteran's service-connected disabilities. 2. Left Upper and Lower Extremity Neuropathy The Veteran contends that his left upper and lower extremity neuropathy is related to service or in the alternative related to a service-connected disorder. In January 2020, the Veteran underwent a VA examination for his neuropathy. The examiner diagnosed the Veteran with neuropathy of the upper right and lower right extremities. The examiner specifically stated that the Veteran did not have a diagnosis of upper right extremity neuropathy and/or lower right extremity neuropathy. The Board notes that VA treatment records document neurological examinations in April and May 2015 that document polyneuropathy. The treatment records indicate pain in all four extremities and decreased pinprick sensation in the bilateral upper extremities. The Board finds that a remand is required. Although the Veteran does not have a formal diagnosis of neuropathy of the left upper and left lower extremities, it appears he had symptoms of pain and decreased sensation. Under Saunders v. Wilkie, symptoms that cause functional impairment is considered a disability for compensation purposes. 886 F.3d 1356, 1363, 1368, 1369 (Fed. Cir. 2018). As such, the Board finds that a remand is required to determine whether the Veteran's symptoms of the left upper extremity neuropathy and left lower extremity neuropathy caused functional impairment, and if so, are secondary to the Veteran's service-connected disabilities. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion from an appropriate clinician regarding the Veteran's hypertension. The examiner must provide the following opinion: (a.) Whether it is at least as likely as not the Veteran's hypertension was caused by a service-connected disability, to include: i. CAD ii. Coronary arteriosclerosis iii. PVD iv. Major depressive disorder v. Headaches (b.) Whether it is at least as likely as not the Veteran's hypertension was aggravated by a service-connected disability, to include: i. CAD ii. Coronary arteriosclerosis iii. PVD iv. Major depressive disorder v. Headaches (c.) The examiner must provide a complete rationale for each opinion given. 2. Obtain an addendum medical opinion from an appropriate clinician regarding the Veteran's left upper and left lower extremity neuropathy. The examiner must provide the following opinion: (a.) Identify any current disability of neuropathy in the upper and lower left extremity, to include any functional impairment caused by pain or loss of sensation noted in the treatment records. i. The examiner should note that a VA neurologist found pain and loss of sensation in all four extremities in April and May 2015. (b.) Whether any identified neuropathy or symptoms which cause functional impairment in the Veteran's left upper and lower extremities is at least as likely as not caused or aggravated by the Veteran's service-connected disabilities. i. The examiner must address the January 2020 VA examiner's opinion that the Veteran's right upper and lower extremity neuropathy was caused by his here in service connected PVD. The examiner must provide a complete medical rationale for all opinions given. J. Dworkin Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Robert Batten 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.