Citation Nr: 21005483 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 12-01 219 DATE: February 1, 2021 ORDER Entitlement to service connection for a brain aneurysm is denied. REMANDED Entitlement to an initial disability rating in excess of 10 percent for gastroesophageal reflux disease (GERD) due to duodenal ulcer prior to March 1, 2016, and in excess of 20 percent thereafter, is remanded. FINDING OF FACT The Veteran’s brain aneurysm has not been shown to be related to service. CONCLUSION OF LAW The criteria for service connection for a brain aneurysm have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1962 to October 1964. These matters come to the Board of Veterans’ Appeals (Board) from a January 2011 rating decision which, in pertinent part, granted service connection for GERD, evaluated at 10 percent, effective August 13, 2010, and denied service connection for a brain aneurysm. In August 2015, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Board videoconference hearing. A copy of the transcript is of record. In a July 2016 rating decision, the RO granted an increased 20 percent evaluation for the Veteran’s GERD due to duodenal ulcer, effective March 1, 2016. In an October 2018 decision, the Board, in pertinent part, denied an increased rating for GERD and service connection for a brain aneurysm. The Veteran appealed the decision to the U.S. Court of Appeals for Veterans Claims (Court). In a June 2019 order, and pursuant to a Joint Motion for Remand (JMR), the Court vacated the Board’s October 2018 decision and remanded the issues back to the Board for action consistent with the JMR. In September 2019, the Board remanded the matters for further development, to include obtaining outstanding VA treatment records. 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; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The U.S. Court of Appeals for Veterans Claims (Court) has held that “Congress specifically limits entitlement to service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability, there can be no valid claim.” Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Entitlement to service connection for a brain aneurysm. The Veteran contends that service connection is warranted for a brain aneurysm. Specifically, he states that he hit his head during a jump in the Airborne while in service and that this caused a brain hemorrhage. In support of his claim, he indicated that the edge of his helmet was near where his aneurysm developed. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran was diagnosed with a subarachnoid hemorrhage in 1996, and evidence shows that the Veteran made jumps as part of the Airborne while in service, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of subarachnoid hemorrhage with headache residuals began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The Veteran’s service treatment records, to include a September 1964 separation examination, are silent for complaints of or treatment for a subarachnoid hemorrhage or aneurysm. Post-service private treatment records reflect that the Veteran complained of occasional tension headaches in February 1982, but was noted to be healthy. In November 1996, the Veteran was admitted to the hospital where he reported onset of a severe, persistent headache one week prior. The Veteran was diagnosed with a subarachnoid hemorrhage of uncertain origin. He continued to report headaches, which were noted to be a normal after effect of a hemorrhage. A February 1997 letter from Dr. J.T. notes that an angiography showed a small aneurysm of the left C4 portion of the cavernous carotid, but that the finding did not explain the Veteran’s headaches. An October 1997 angiography was negative for an aneurysm. February 2005 and September 2006 MRI imaging studies were also negative for an aneurysm. The Veteran was afforded a VA examination in March 2016. The Veteran reported 20 to 25 jumps with the Airborne, several of which were rough, but that he did not report to sick call for them and “sucked” it up. The Veteran reported onset of a severe headache over the period of a week in 1996 and that a lumbar puncture revealed blood in his cerebrospinal fluid, indicating a subarachnoid bleed. He denied residual neurological effects from the bleed. The Veteran was noted to have a cerebral aneurysm, but that follow-up imaging studies over the years had been normal. After examining the Veteran and reviewing the claims file and medical records, the examiner conceded that the Veteran experienced rough landings with trauma to the body, including the head, during Airborne training. The examiner explained, however, that the type of trauma described by the Veteran did not produce cerebral aneurysms. Rather, trauma severe enough to cause intracranial bleeding would produce bleeding either immediately after the trauma or within a few days of the trauma and is often catastrophic or fatal, since the blood vessels in the brain actually tear. Aneurysms, the examiner explained, are developmental and often congenital abnormalities of the arterial wall that lead to weakening and ballooning of the wall, which over time, may rupture. The examiner found that even in the absence of an aneurysm, head trauma in service would not result in cerebral bleeding 30 years later. Thus, the examiner opined that the Veteran’s aneurysm was less likely than not caused by the claimed in-service injury, event, or illness. The Board finds the March 2016 examiner’s opinion is probative, as it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). While the Veteran is competent to report having experienced rough jumps in service, including hits to his head, he is not competent to provide a diagnosis in this case or determine that any aneurysm or subarachnoid hemorrhage was a manifestation of an in-service head injury. The issue is medically complex, as it requires knowledge and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, the claim of service connection for an aneurysm is denied. REASONS FOR REMAND Entitlement to an initial disability rating in excess of 10 percent for gastroesophageal reflux disease (GERD) due to duodenal ulcer prior to March 1, 2016, and in excess of 20 percent thereafter, is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to an initial disability rating in excess of 10 percent for GERD prior to March 1, 2016, and in excess of 20 percent thereafter, at this time. Specifically, the Veteran’s GERD is rated under 38 C.F.R. § 4.114, Diagnostic Code (DC) 7346 prior to March 1, 2016, and under DC 7346-7305 thereafter. A review of the record reflects that the Veteran’s disability requires continuous medication to control. The Board notes that DCs 7305 and 7346 do not account for the ameliorative effects of medication. The nature and severity of the Veteran’s symptoms without the ameliorative effects of medication are not shown by the record. Because such is primarily a medical question, the Board finds that a remand for a new VA examination is necessary. The matter is REMANDED for the following actions: 1. Obtain the Veteran’s VA treatment records for the period from October 2020 to present. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected GERD. 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 comment on the presence or absence of the following: persistently recurrent epigastric distress; dysphagia, pyrosis; regurgitation; substernal or arm or shoulder pain; considerable impairment of health; vomiting; material weight loss; hematemesis or melena, with moderate anemia; constipation, diarrhea, abdominal distress, and pain, as well as other disturbances in bowel function associated with the gastrointestinal disability, and describe any health impairment, to include whether it is mild, moderate, or severe. The examiner should specifically note the medication the Veteran takes to control his GERD, and comment, to the extent possible, on the additional symptoms and related impairment that would be present throughout the appeal period without the relief provided by medication used to treat the condition. 3. After completing the above, and any other development as may be indicated, the Veteran’s claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Owen, 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.