Citation Nr: 21076444 Decision Date: 12/23/21 Archive Date: 12/23/21 DOCKET NO. 16-05 592 DATE: December 23, 2021 ORDER Entitlement to service connection for a heart disability is denied. REMANDED Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a genitourinary disability, to include left varicocele, is remanded. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran's heart disability was incurred in service. CONCLUSION OF LAW The criteria for entitlement to service connection for a heart disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1983 to August 1990. The matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the claim in June 2019 for further development by the RO. The case has been returned to the Board for further appellate action. The Board finds that there was substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The June 2019 Board remand directed the agency of original jurisdiction (AOJ) to attempt to verify all periods of service after August 1990 and, if applicable, obtain any service records for any such periods. The AOJ informed the Veteran that its review found that he was transferred to an Army Reserve Unit following his service period ending in August 1990 and that no orders for any additional periods of Active Duty for Training (ACDUTRA) and or Inactive Duty for Training (INACDUTRA) were found. See September 2019 Subsequent Development Letter. The Veteran was afforded an opportunity to dispute these findings and submit any additional pertinent evidence. Id. The record does not show that the Veteran contested these findings or submitted additional service records. Additionally, the AOJ obtained a VA examination and medical opinion regarding the heart disability, as directed, and as discussed in further detail below. Therefore, the Board will proceed with adjudication of the claim. The Board notes that, following remand, the RO granted service connection for bilateral hearing loss in a June 2021 rating decision. As this is a full grant of this issue, it is no longer in appellate status. The Board also notes that a service connection claim for a right knee disability is presently under appeal pursuant to the Veterans Appeals Improvement and Modernization Act, also known as the Appeals Modernization Act (AMA). See October 2021 VA Form 10182. The Veteran's representative has previously argued that the left and right knee claims are inextricably intertwined. See April 2019 third party correspondence. However, as claims adjudicated in different legal systems, i.e., the legacy and AMA systems, cannot be merged, the AMA claim must be considered separately and, thus, is not before the Board at this time. SERVICE CONNECTION 1. Entitlement to service connection for a heart disability The Board finds that the preponderance of the evidence does not show that Veteran has a heart disability that is related to service. Thus, an award of service connection is not warranted. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303(a). 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). The record in this case is clear as to whether the Veteran has a heart disability. The June 2021 VA examination shows a diagnosis of valvular heart disease, a first-degree atrioventricular block, and dilated aortic root and dilated ascending aorta. See also CAPRI records received by VA in October 2021 (noting abnormal echocardiogram and atypical chest pain). Thus, the first element of service connection, the existence of a current disability, is satisfied. Concerning the in-service event, illness, or injury, the Veteran's service treatment records (STRs) show that he reported pain or pressure in his chest in a June 1986 examination (report of medical history). He also reported chest pain after eating, occurring approximately every month or two, with no association to exercise, in the same examination. The Board acknowledges the assertion that the Veteran's heart disability is related to service. However, the Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex. He does not have the requisite specialized knowledge, training, or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Thus, although the Board has carefully considered the lay assertion that the Veteran's heart disability began during service, the Board ultimately affords the objective medical evidence of record, which weighs against finding such a connection, with greater probative weight than the lay opinion. Consequently, the Board affords more probative weight to the competent medical evidence of the June 2021 VA examination report and medical opinion. Here, the Board finds that the June 2021 VA medical opinion is based on an accurate medical and lay history as well as medical documentation provided in the claims file, to include the Veteran's STRs. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (noting that most of the probative value of a medical opinion comes from its reasoning). The examiner acknowledged the relevant STRs but noted no heart problem in service; the examiner also addressed the more probable etiologies of the Veteran's currently diagnosed heart disability. Additionally, neither the Veteran nor his representative have presented or identified any contrary medical opinion or medical treatment record that supports his claim. The Veteran also has not provided any lay statements regarding his symptoms in or following service through the present. The Board acknowledges that VA treatment records indicate the presence of benign hypertension. See CAPRI records received by VA in October 2021. The Veteran has not submitted a claim for service connection for hypertension, and such claim is not presently before the Board. However, to the extent that such claim can be inferred, the Board does not find that a remand is necessary to obtain a separate VA examination or medical opinion regarding hypertension. Here, there is no evidence of in-service complaints or diagnoses of, or treatment for, hypertension or elevated blood pressure in the Veteran's STRs. The Veteran has not submitted any statements, medical opinions, or treatment records indicating that his noted hypertension may be associated with service. Therefore, remand to obtain a medical opinion is not necessary. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine cannot be applied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Thus, service connection for a heart disability is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for a left knee disability is remanded. Although further delay is regrettable, the Board finds that additional development is necessary prior to appellate review. Specifically, a remand is warranted in order to obtain an addendum medical opinion regarding the etiology of the Veteran's left knee disability. The RO obtained a June 2021 VA examination, which diagnosed bilateral knee strain and left knee osteoarthritis, and a medical opinion, which opined against service connection on a direct theory of entitlement and attributed the left knee condition to a non-service-connected right knee condition. The opinion states that the Veteran's STRs include right knee complaints but none for the left knee. However, this medical opinion is inadequate. It does not address the Veteran's lay statement that he injured both knees in a 1985 basketball game and has experienced knee pain since then. See April 2019 correspondence. The opinion also does not address an April 1991 medical treatment record noting year-long stiffness of the left knee with prolonged sitting or the 1992 left knee arthroscopy. See April 1991 medical treatment record received by VA in May 2014; and November 1992 private medical treatment record received by VA in May 2014. Thus, the case must be returned for an addendum opinion. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (holding that once VA undertakes an examination, it must provide an adequate one). Moreover, as the VA examination noted a diagnosis of left knee osteoarthritis, a medical opinion is necessary regarding service connection on a presumptive basis for chronic diseases pursuant to 38 C.F.R. § 3.309(a). 2. Entitlement to service connection for a genitourinary disability, to include left varicocele, is remanded. Remand is also warranted in order to obtain an addendum medical opinion regarding the etiology of the Veteran's genitourinary disability. The RO obtained a June 2021 VA examination, which noted a diagnosis of varicocele, status-post surgery, as well as the Veteran's reports of current symptoms, to include excessive urination, difficulty with sexual performance and infertility. The RO also obtained a medical opinion, which opined against service connection. The opinion states that the Veteran does not have a "confirmed diagnosis" of a current genitourinary disability, that varicocele might cause infertility or testicle damage, and that his diagnosis of varicocele, status-post surgery, was less likely than not caused by service. However, this medical opinion is inadequate. It does not address the Veteran's lay statements regarding his current urinary and reproductive symptoms, as reported in the VA examination. See also May 2021 VA Form 21-4138 (statement in support of claim by the Veteran's spouse, reporting his frequent nightly urination, intimacy issues, and infertility). Additionally, it does not address VA medical treatment records indicating the presence of a large prostate and benign prostatic hyperplasia. See CAPRI records received by VA in October 2021. It also does not address the etiology of the acknowledged varicocele condition; rather it merely discusses that varicocele can contribute to infertility or testicle damage. The case must be returned for an addendum opinion. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. Thereafter, obtain an addendum opinion from the VA examiner who performed the June 2021 examination or an appropriate medical professional if the examiner is unavailable regarding the nature and etiology of any left knee disability. A new examination of the Veteran is only necessary if deemed so by the examiner. The claims file, as updated, must be made available to and reviewed by the examiner. The examiner is asked to opine on the following: (a) Is it as least as likely as not (a 50 percent probability or greater) that any currently diagnosed left knee disability is etiologically related, in whole or in part, to the Veteran's active service? (b) Alternatively, is it at least as likely as not (a 50 percent or greater probability) that the Veteran's left knee osteoarthritis (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? The Board calls the examiner's attention to the pertinent lay statements and medical evidence of record: the Veteran's correspondence received by VA in April 2019; an April 1991 medical treatment record noting year-long stiffness of the left knee with prolonged sitting received by VA in May 2014; and a November 1992 private medical treatment record regarding left knee arthroscopy received by VA in May 2014. A complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and must state whether there is additional evidence that would permit the necessary opinion to be made. 2. Following completion of directive #1, obtain an addendum opinion from the VA examiner who performed the June 2021 examination or an appropriate medical professional if the examiner is unavailable regarding the nature and etiology of any genitourinary disability. A new examination of the Veteran is only necessary if deemed so by the examiner. The claims file, as updated, must be made available to and reviewed by the examiner. The examiner is asked to opine on whether it is as least as likely as not (a 50 percent probability or greater) that any currently diagnosed genitourinary disability is etiologically related, in whole or in part, to the Veteran's active service. The Board calls the examiner's attention to the lay statements regarding the Veteran's current urinary and reproductive symptoms as reported in the June 2021 VA examination and the May 2021 VA Form 21-4138 (statement in support of claim by the Veteran's spouse), as well as CAPRI records received by VA in October 2021 noting the presence of a large prostate and benign prostatic hyperplasia. (Continued on the next page) A complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and must state whether there is additional evidence that would permit the necessary opinion to be made. SONJA S. AN Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Minaya, 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.