Citation Nr: 21077520 Decision Date: 12/30/21 Archive Date: 12/30/21 DOCKET NO. 17-45 698 DATE: December 30, 2021 ORDER Service connection for a left knee disorder, to include meniscal tear with degenerative arthritis, is granted. REMANDED Service connection for diabetes mellitus is remanded. Service connection for hypertension is remanded. Entitlement to an initial rating higher than 10 percent for gastroesophageal reflux disease (GERD) with hiatal hernia is remanded. FINDING OF FACT The evidence is at least in equipoise as to whether the Veteran's left knee disorder is related to active service. CONCLUSION OF LAW The criteria for service connection for a left knee disorder, to include meniscal tear with degenerative arthritis, are met. 38 U.S.C. § 1110, 5107; 38 C.F.R. § 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1962 to November 1965 in the United States Army. He was awarded the Combat Infantryman Badge. This matter comes before the Board of Veterans' Appeals (Board) from March 2017 and November 2017 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. In April 2019, the Board denied the Veteran's claims for service connection for a left knee disorder and an increased rating for GERD with hiatal hernia. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In a March 2021 Memorandum Decision, the Court vacated the April 2019 Board decision and remanded the issues to the Board. In November 2020, the Board denied the Veteran's claims for service connection for diabetes mellitus and hypertension. The Veteran appealed this decision to the Court. Pursuant to a July 2021 Joint Motion for Remand (JMR), the Court vacated the November 2020 Board decision and remanded the issues to the Board. Service Connection for a Left Knee Disorder The Veteran contends that his left knee disorder is related to parachute jumping during service. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 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 Veteran has a diagnosis of left knee meniscal tear and degenerative arthritis. See December 2016 VA Examination. The Veteran reported that he served in the Army as a parachutist with 35 jumps. Id. The Veteran's military personnel records document several jumps throughout his active-duty service and his DD Form 214 shows that he was awarded the Parachutist Badge. Accordingly, the first two elements of service connection are established. Regarding the third element, medical nexus, the December 2016 VA examiner opined that it would be mere speculation to attribute the Veteran's left knee disorder to parachute jumps during service versus secondary to the advanced left hip osteoarthritis noted as early as 1975 versus the effects of aging and/or occupation because the Veteran's left knee condition is likely multifactorial to include all of the above identified risk factors. Based on the foregoing, the Board finds that the evidence is at least in equipoise as to whether the Veteran's left knee disorder is related to active service. The December 2016 VA examiner concluded that the etiology of the Veteran's left knee disorder was multifactorial, including due to parachute jumps during active service. Accordingly, resolving reasonable doubt in favor of the Veteran, service connection for a left knee disorder is granted. REASONS FOR REMAND Service Connection for Diabetes Mellitus and Hypertension The Veteran contends that his service-connected posttraumatic stress disorder (PTSD) with depressive disorder and erectile dysfunction caused or aggravated his diabetes mellitus and hypertension. Specifically, the Veteran asserts that his PTSD with depressive disorder and erectile dysfunction caused him to gain weight, which, in turn, caused or aggravated his diabetes mellitus and hypertension. Additionally, the Veteran asserts that PTSD is associated with a higher risk for cardiovascular disease, to include hypertension. The Veteran was afforded VA examinations in January 2020 for his diabetes mellitus and hypertension. The examiner opined that the Veteran's diabetes mellitus and hypertension are less likely than not proximately due to, the result of, or aggravated by his PTSD with depressive disorder and erectile dysfunction. The rationale stated that the Veteran was diagnosed with diabetes mellitus and hypertension prior to his diagnosis or treatment for PTSD and the Veteran's weight gain coincided with a left total knee replacement. The Board finds this opinion inadequate because the examiner did not consider whether the Veteran had symptoms of PTSD prior to his diagnosis of diabetes mellitus and hypertension. Additionally, the examiner did not address the medical treaties submitted by the Veteran regarding the relationship between PTSD and cardiovascular disease. Accordingly, remand is warranted to obtain new VA opinions. Additionally, the January 2020 VA examiner stated that the Veteran's weight did not maintain an increase until after a left total knee replacement. As service connection for a left knee disorder has been granted herein, an opinion should be obtained on remand regarding whether the Veteran's left knee disorder caused or aggravated his diabetes mellitus and hypertension, to include due to weight gain. Increased Rating for GERD with Hiatal Hernia The Veteran contends that a higher rating is warranted for his service-connected GERD with hiatal hernia. The medical evidence of record indicates that the Veteran requires continuous use of medication to relieve symptoms of his service-connected GERD with hiatal hernia. Based on such evidence, in the March 2021 Memorandum Decision, the Court found that the April 2019 Board decision did not consider the severity of the Veteran's GERD with hiatal hernia without the ameliorative effects of medication. As such, a remand is necessary for a VA examination to obtain a medical opinion addressing the severity of the Veteran's service-connected GERD with hiatal hernia without the ameliorative effects of medication. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records. 2. Obtain a VA opinion from an appropriate clinician to determine the nature and etiology of the Veteran's diabetes mellitus. The claims file, including a copy of this Remand, must be made available to the clinician and the clinician should indicate in his/her report whether or not such was reviewed. If an examination is deemed necessary by the clinician, one should be scheduled, and all necessary tests and studies should be accomplished and reported in detail. After complete review of the file, the clinician should opine as to the following: (a.) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran's diabetes mellitus was caused by his service-connected PTSD with depressive disorder and erectile dysfunction or left knee disability, to include medications and treatment. (b.) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran's diabetes mellitus was aggravated by his service-connected PTSD with depressive disorder and erectile dysfunction or left knee disability, to include medications and treatment. (c.) Whether it is at least as likely as not that obesity served as an "intermediate step" between the Veteran's service-connected disabilities and his diabetes mellitus, to include medications and treatment. The clinician should opine whether the Veteran's service-connected disabilities caused or aggravated the Veteran's obesity. If so, was the obesity that resulted from the service-connected disabilities a substantial factor in causing his diabetes mellitus? Would his disability have occurred, but for the obesity caused by the service-connected disabilities? The clinician should consider the Veteran's medical history and lay statements of record. The clinician must also address the June 2009 VA examination noting that the Veteran's PTSD symptoms began in the 1960s. The clinician must address the Veteran's argument that his PTSD caused weight gain, which, in turn, caused or aggravated his diabetes mellitus. The clinician must review and comment on the treatise evidence submitted by the Veteran in support of this argument, including (1) PTSD and Cardiovascular Disease, (2) Psychological Stress and Changes in Weight Among US Adults, and (3) The Weight of Traumatic Stress. If necessary, and to the extent possible, the clinician should reconcile his or her opinion with this evidence. A fully articulated medical rationale for any opinion expressed must be set forth in the medical report. The clinician should discuss the particulars of this Veteran's history and the relevant medical science as applicable to this case, which may reasonably explain the medical guidance in the study of this case. If the clinician cannot provide the requested opinions without resorting to speculation, he/she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 3. Obtain a VA opinion from an appropriate clinician to determine the nature and etiology of the Veteran's hypertension. The claims file, including a copy of this Remand, must be made available to the clinician and the clinician should indicate in his/her report whether or not such was reviewed. If an examination is deemed necessary by the clinician, one should be scheduled, and all necessary tests and studies should be accomplished and reported in detail. After complete review of the file, the clinician should opine as to the following: (a.) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran's hypertension was caused by his service-connected PTSD with depressive disorder and erectile dysfunction or left knee disability, to include medications and treatment. (b.) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran's hypertension was aggravated by his service-connected PTSD with depressive disorder and erectile dysfunction or left knee disability, to include medications and treatment. (c.) Whether it is at least as likely as not that obesity served as an "intermediate step" between the Veteran's service-connected disabilities and his hypertension, to include medications and treatment. The clinician should opine whether the Veteran's service-connected disabilities caused or aggravated his obesity. If so, was the obesity that resulted from the service-connected disabilities a substantial factor in causing his hypertension? Would his disability have occurred, but for the obesity caused by the service-connected disabilities? The clinician should consider the Veteran's medical history and lay statements of record. The clinician must also address the June 2009 VA examination noting that the Veteran's PTSD symptoms began in the 1960s. The clinician must address the Veteran's arguments that (1) his PTSD caused weight gain, which, in turn, caused or aggravated his hypertension and (2) that PTSD is associated with a higher risk for cardiovascular disease, to include hypertension. The clinician must review and comment on the treatise evidence submitted by the Veteran in support of this argument, including (1) PTSD and Cardiovascular Disease, (2) Psychological Stress and Changes in Weight Among US Adults, and (3) The Weight of Traumatic Stress. If necessary, and to the extent possible, the clinician should reconcile his or her opinion with this evidence. A fully articulated medical rationale for any opinion expressed must be set forth in the medical report. The clinician should discuss the particulars of this Veteran's history and the relevant medical science as applicable to this case, which may reasonably explain the medical guidance in the study of this case. If the clinician cannot provide the requested opinions without resorting to speculation, he/she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 4. Schedule the Veteran for a VA examination by an appropriate clinician to determine the current severity of the Veteran's gastroesophageal reflux disease (GERD) with hiatal hernia. The claims file, including a copy of this Remand, must be made available to the examiner and the examiner should indicate in his/her report whether or not such was reviewed. All necessary tests and studies should be accomplished. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The examiner should specifically comment on the severity of the Veteran's GERD with hiatal hernia in the absence of the ameliorative effects provided by medication used to treat his GERD with hiatal hernia. A complete rationale should be provided for the opinions offered. If an opinion cannot be offered without resort to mere speculation, the reason for this should be fully explained in the opinion. C.B. IWANOWSKI Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Kernen, 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.