Citation Nr: 21074975 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 17-14 289 DATE: December 16, 2021 ORDER Entitlement to service connection for ischemic heart disease (IHD), to include as a result of herbicide agent exposure, trichloroethylene (TCE) exposure, extreme cold exposure, or as secondary to the Veteran's service-connected disabilities is denied. REMANDED Entitlement to service connection for diabetes mellitus, to include as a result of herbicide agent exposure, TCE exposure, extreme cold exposure or as secondary to the Veteran's service-connected disabilities is remanded. FINDING OF FACT The preponderance of the evidence is against finding that IHD, began during active service, or is otherwise related to an in-service event, injury, or disease, to include as due to service-connected disabilities. CONCLUSION OF LAW The criteria for service connection for IHD, to include as a result of herbicide agent exposure, TCE exposure, extreme cold exposure, or as secondary to the Veteran's service-connected disabilities have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.309 REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Air Force from August 1954 to April 1978. In October 2020, the Board remanded the issues on appeal for further development, and the case has since been returned to the Board. With regards to the issue of service connection for diabetes, the Board finds that the agency of original jurisdiction (AOJ) has not substantially complied with the remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 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). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. See 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) Entitlement to service connection for ischemic heart disease, to include as a result of herbicide agent exposure, TCE exposure, extreme cold exposure, or as secondary to the Veteran's service-connected disabilities The Veteran alleges that he suffers from ischemic heart disease as a result of his active-duty service, specifically as a result of his claimed in-service herbicide exposure and extreme cold exposure. In the alternative, it has been alleged that such are secondary to his now service-connected disabilities. The Veteran also asserted exposure to TCE to which the Board has previously conceded exposure. In July 2014 the Veteran underwent an Ischemic Heart Disease examination with an accompanying DBQ. The examiner diagnosed the Veteran with coronary artery disease and opined that it was as likely as not that the Veteran's heart condition "may or may not" be caused by military service. However, in the July 2019 Board remand, this opinion was found to be speculative in nature and a new examination with accompanying opinion was ordered. In December 2019, the Veteran attended a VA Heart examination. In pertinent part, the examiner opined that there was "no pathology between the CAD and the Scar, Tip of left Index Finger, Scar, right middle finger, scar, left wrist."; "There is no pathology between the CAD and Varicose Veins. Therefore no aggravation", and "After reviewing the medical record there are no medical evidence that he had CAD with one year of the veteran's service separation." However, in an October 2020 remand, the Board found this opinion to be inadequate because the examiner failed to provide an adequate rationale for his responses regarding the claimed disorders and the event or disability in question, and addendum opinions were ordered. In July 2021, an addendum opinion was provided. The examiner opined the Veteran's IHD was less likely than not due to his active service. The rationale provided was: MO 1: Per the c-file and pertinent records, on the report for medical history of 4/20/1978, veteran checked palpitation or pounding heart sound. There were no further complaints or diagnoses related to a heart condition thereafter (a period of 25 years) until it was noted in the records that veteran had ischemic heart disease in 2003, coronary heart disease in 2004, status post CABG 2004 at Midwest City Regional medical center. The DBQ of 2014 reported he retired early because of the declining health condition. Veteran has a triple bypass surgery with graft sites that are noted on scar DBQ. Veteran seen for chest pain in 2006 and 2007. Veteran first A1C of 6.9 was reported in 2016 and is 38 years later. No other records show treatment of ischemic heart disease and diabetes mellitus during service. There are no records showing that veteran was exposed TCE exposure and extreme cold temperatures. It is not likely, veteran's claim of A) ISCHEMICHEART DISEASE, B) DIABETES MELLITUS had it's onset during any period of service or otherwise related to such periods of service to include THE VETERANS TRICHLOROETHYLENE (TCE) EXPOSURE AND/OR EXTREME COLD EXPOSURE DURING SERVICE. It is less likely than not that the veteran's diagnosed conditions of diabetes mellitus, coronary artery disease status post CABG, triple bypass surgery and hypertensive heart disease had their onset during any period of service or otherwise related to such periods of service to include THE VETERANS TRICHLOROETHYLENE (TCE) EXPOSURE AND/OR EXTREME COLD EXPOSURE DURING SERVICE The examiner also opined that the Veteran's IHD was not aggravated by his service-connected disabilities. The rationale stated was: In 1978 on the report of medical examination, it was noted that bilateral varicose veins, cramps in the legs due to prolong sitting but no treatment was required was noted on report of medical history of 1978. There is no objective evidence in support of any aggravation or treatment of varicose vein during or after service. MO 3: Per the c-file and pertinent records, In 1978 on the report of medical examination, it was noted that bilateral varicose veins, cramps in the legs due to prolonged sitting but no treatment was required was noted on report of medical history of 1978. According to Society for Cardiovascular angiography and interventions (2014) "while the presence of varicose veins indicates a problem with moving blood back to the heart for oxygenation, generally a diagnosis of varicose veins itself does NOT put you at a higher risk for cardiac issues and it is NOT the same as peripheral vascular disease". http://www.secondscount.org/heart-condition-centers/info-detail-2/peripheral-vascular-disease-how-problems-with-arte#.YOt6uBNKg1gSo, It is NOT likely veteran's claim of ischemic heart disease was aggravated beyond it natural progression by the VETERAN'S SERVICE CONNECTED VARICOSE VEINS. MO 4: Per the c-file and pertinent records, A) veteran was SC for sleep apnea in 2004and started using CPAP. The report of medical examination noted veteran had tonsillectomy in childhood with normal recovery and no complication in 1958. No other objective evidence showing any sleep problems during service. B) veteran SC for right knee status post total arthroplasty in 2015. C) Unable to locate any objective evidence of left hip arthritis s/o trochanteric fracture during service. D) No objective evidence of right knee osteoarthritis with instability noted in the medical records during service. E) In the chronological records of medical care reported veteran was seen for right shoulder pain treated with heat and aspirin. F) veteran is SC for right hip osteoarthritis in 2015with no symptoms or service treatments noted during service. G) Per the c-file, veteran is SC for right knee osteoarthritis with limitation of motion in 2015. H) Per the c-file records, veteran is SC for right hip osteoarthritis with limitation of extension in 2015 but no objective evidence of right hip problems during service. I) Per the c-file records, veteran is SC for right hip osteoarthritis with limitation of flexion in 2015 but no objective evidence of right hip problems during service. J) Per the c-file and pertinent records, In 1978 on the report of medical examination, it was noted that bilateral varicose veins. cramps in the legs due to prolong sitting but no treatment was required was noted on report of medical history of 1978. The earliest in was noted veteran was treated for diabetes was in 2006. However, there is NO correlationship of service connected condition with diabetes in the service symptoms during service. It is NOT likely veteran's claim of diabetes mellitus was aggravated beyond its natural progression by the veteran's SC disabilities. In September 2021, an addendum opinion was provided. The examiner opined that the Veteran's IHD was not proximately due to his service connected disabilities. The rationale provided was: MO 1: Per the c-file and pertinent records, on the report for medical history of 4/20/1978, veteran checked palpitation or pounding heart sound. There were no further complaints or diagnoses related to a heart condition thereafter (a period of 25 years) until it was noted in the records that veteran had ischemic heart disease in 2003, coronary heart disease in 2004, status post CABG 2004 at Midwest City Regional medical center. A) BILATERALHEARING LOSS: service connection for tinnitus and hearing loss for 2015. B) TINNITUS: service connection for tinnitus and hearing loss for 2015. C) SLEEP APNEA: veteran was SC for sleep apnea in 2004 and started using CPAP. The report of medical examination noted veteran had tonsillectomy in childhood with normal recovery and no complication in 1958. No other objective evidence showing any sleep problems during service. D) RIGHT KNEE STATUS POST TOTAL ARTHROPLASTY: veteran SC for right knee status post total arthroplasty in 2015. E) LEFT HIP ARTHRITIS STATUS POST TROCHANTERIC FRACTURE AND TOTAL HIP REPLACEMENT WITH TROCHANTERIC PAIN SYNDROME: Unable to locate any objective evidence of left hip arthritis s/o trochanteric fracture during service. F) RIGHT KNEE OSTEOARTHRITIS WITH INSTABILITY: No objective evidence of right knee osteoarthritis with instability noted in the medical records during service. G) RIGHT SHOULDER OSTEOARTHRITIS WITH BURSITIS AND IMPINGEMENT SYNDROME: Chronological records 10/3/1961reported pain right shoulder diagnosed mild sprain. H) RIGHT HIP OSTEOARTHRITIS WITH LIMITATION OF ABDUCTION, ADDUCTION, AND ROTATION: Unable to locate any objective evidence of left hip arthritis s/o trochanteric fracture during service. I) RIGHT KNEE OSTEOARTHRITIS WITH LIMITATION OF MOTION: Per the c-file, veteran is SC for right knee osteoarthritis with limitation of motion in 2015. J) PIGMENTARY RESIDUALS OF SKIN CONDITION: Report of medical examination 4/20/1978 noted possible tinea versicolor both upper thigs, edically K) SURGICAL SCAR, RIGHT KNEE: veteran SC for right knee scar status post total arthroplasty in 2015. L) RIGHT HIP OSTEOARTHRITIS WITH LIMITATION OF EXTENSION: Per the c-file records, veteran is SC for right hip osteoarthritis with limitation of extension in 2015 but no objective evidence of right hip problems during service. M) RIGHT HIP OSTEOARTHRITIS WITH LIMITATION OF FLEXION: Per the c-file records, veteran is SC for right hip osteoarthritis with limitation of flexion in 2015 but no objective evidence of right hip problems during service. N) SURGICAL SCAR, LEFT HIP: Unable to locate any objective evidence of left hip arthritis s/o trochanteric fracture during service. O) VARICOSE VEINS: In 1978 on the report of medical examination, it was noted that bilateral varicose veins, cramps in the legs due to prolong sitting but no treatment was required was noted on report of medical history of 1978. According to Society for Cardiovascular angiography and interventions (2014) "while the presence of varicose veins indicates a problem with moving blood back to the heart for oxygenation, generally a diagnosis of varicose veins itself does NOT put you at a higher risk for cardiac issues and it is NOT the same as peripheral vascular disease". http://www.secondscount.org/heart-condition-centers/infodetail-2/peripheral-vascular-disease-how-problems-with-arte#.YOt6uBNKg1g P) CYST, LEFT SCALP: clinical record tissue examination on 09/22/1964 noted lesion middle finger right and lesion on scalp. cutaneous nodule extensor surface right middle finger present approximately 1 year. Lesion scalp present many years with recent symptoms of pruritidis. Final diagnosis was skin right middle finger, suepidermal nodule fibrosis/dermatofibroma skin, scalp, benign hyperkeratosis. Q) SCAR, RIGHT MIDDLE FINGER: clinical record tissue examination on 09/22/1964 noted lesion middle finger right and lesion on scalp. cutaneous nodule extensor surface right middle finger present approximately 1 year. Lesion scalp present many years with recent symptoms of pruritidis. Final diagnosis was skin right middle finger, suepidermal nodule fibrosis/dermatofibroma skin, scalp, benign hyperkeratosis. R) SCAR, TIP OF LEFT INDEX FINGER: Chronological records 8/18/1964 reported small laceration on left hand, tetanus vac administered. S) SCAR, LEFT WRIST: Laceration of left wrist for knife cut 1964. Based on all the conditions above, there are no medical research linking all the above conditions related to heart problems. So, It is NOT likely Veteran's claim of ISCHEMIC HEART DISEASE was caused by the conditions described above. The remaining evidence of record details continued complaints of IHD but no discussion on its etiology. Based on the foregoing evidence of record, the Board finds that service connection is not warranted. The Board finds the July and September 2021 VA opinions of record the most probative evidence of record as to the etiology of the Veteran's IHD because they are based on an accurate medical history and provides explanations that contained clear conclusions and supporting data. The Board considered the Veteran's lay assertions as to the etiology of his IHD. Although the Veteran is competent to attest to his experiences, he is not competent in these circumstances to opine as to the etiology of his IHD. The Veteran has not been shown to have specialized medical knowledge that would be necessary to provide a competent opinion regarding service connection. The Board finds the July and September 2021 VA opinions of record to be more probative in this regard. The examiner considered the Veteran's history, and ultimately concluded that from a medical perspective, it is less likely that his IHD is related to service nor was it proximately due to or aggravated by his service-connected disabilities. In conclusion, the weight of the evidence is against the claim for service connection for IHD. REASONS FOR REMAND Entitlement to service connection for diabetes mellitus, to include as a result of herbicide agent exposure, TCE exposure, extreme cold exposure or as secondary to the Veteran's service-connected disabilities is remanded. In the October 2021 Board remand, the AOJ was directed to obtain an addendum opinion. Specifically, the examiner was directed to provide opinions on proximation and aggravation. While the Board notes the July 2021 opinion addresses direction service connection, it does not address secondary service connection for either proximation or aggravation. Accordingly, an addendum opinion is required. The matters are REMANDED for the following action: Forward the claims file to an appropriate clinician for an addendum opinion regarding the Veteran's claimed diabetes mellitus. After a review of the record, the examiner should provide an opinion responding to the following: Is it at least as likely as not that the disability: (a) was caused OR (b) is aggravated (worsened beyond natural progression) by any of the Veteran's service-connected disabilities? If aggravation is found, the physician should attempt to quantify the degree of additional disability resulting from the aggravation A detailed explanation (rationale) is requested for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested) L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. A. Elliott II, 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.