Citation Nr: 21009087 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 15-08 075 DATE: February 18, 2021 REMANDED Entitlement to service connection for a disability manifesting in headaches, claimed as aneurysms and calcifications of the brain, is remanded. Entitlement to service connection for large duodenum ulcer/peptic ulcer, to include as due to service-connected disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1969 to December 1970. The Veteran had a videoconference hearing before the undersigned in August 2018. A transcript of the hearing has been associated with the claims file. 1. Entitlement to service connection for a disability manifesting in headaches, claimed as aneurysms and calcifications of the brain, is remanded. As noted in prior Board remands, the Veteran asserts he has a current disability manifesting in headaches. He specifically attributes these headaches to brain aneurysms and calcifications discovered and treated in 2013. He contends that during his period of active duty service, he suffered from headaches, and that such should be determined to be incurred or aggravated during service. The evidence of record indicates that the Veteran had a brain hemorrhage at age 16, prior to active duty service. Pertinently, at his April 1969 examination upon entrance into the service, no residual disability was identified. Indeed, the April 1969 examination report specifically stated that the Veteran had a “complete recovery” from a prior subarachnoid hemorrhage. Per the Board’s request, the agency of original jurisdiction (AOJ) has obtained medical opinions addressing the etiology of the Veteran’s headaches and his brain aneurysms/calcifications, but they do not adequately discuss whether the Veteran’s current disability or disabilities preexisted service. As such, presently, the presumption of soundness has not been rebutted. Where the government fails to rebut the presumption of soundness, the Veteran’s claim must be considered one for service incurrence or direct service connection. With this presumption in mind, the key question at issue is not whether the Veteran’s pre-existing brain hemorrhage was aggravated during service, but rather whether the Veteran’s current disability or disabilities at least as likely as not had onset in, or are otherwise related to service. As noted above, the Veteran reports that he experienced headaches during service while serving in Vietnam. He reports working in close proximity to cannon fire and recalls experiencing in-service headaches after firing them. During his August 2018 hearing, the Veteran stated that during a 2013 scan, his doctors found three calcified aneurysms with blood clots in his brain. The Veteran reported that his doctors noted that the largest calcification looked decades old. A November 2019 VA headaches examination identified a diagnosis of tension headaches. The examiner noted that the Veteran had experienced headaches with his 1965 pre-service brain hemorrhage, but those subsided. He started experiencing headaches again during service. Without further explanation, the examiner noted that the Veteran’s headaches were “unrelated to aneurysm.” A subsequent medical opinion obtained in September 2020 noted possible risk factors for the development of an aneurysm but did not otherwise address whether the Veteran’s headaches were a manifestation of his 2013 aneurysm and calcifications, or representative of a separate disability notwithstanding aneurysm risk factors. On remand, opinions should be obtained addressing the Veteran’s service-connection claim on a direct basis. 2. Entitlement to service connection for large duodenum ulcer/peptic ulcer, to include as due to service-connected disabilities, is remanded. In the September 2020 remand directives, the examiner was asked to provide an opinion as to whether the Veteran’s duodenum/peptic ulcer disability was caused or aggravated beyond its natural progression by his service-connected posttraumatic stress disorder (PTSD); however an opinion was not offered in the September 2020 examination report. Additionally, the Veteran was granted entitlement to service connection for gastroesophageal reflux disease (GERD) with cricopharyngeal achalasia in November 2020. As remand is already warranted, the clinician should offer an opinion as to whether the Veteran’s duodenum/peptic ulcer disability was caused or aggravated beyond its natural progression by his now service-connected GERD with cricopharyngeal achalasia. The matters are REMANDED for the following action: 1. Obtain a medical opinion from a clinician other than the September 2020 examiner addressing the nature and etiology of the Veteran’s headache disability, claimed as aneurysms and calcifications of the brain. The claims file should be sent to, and reviewed by the clinician. Upon review of the file, the reviewing clinician should respond to each of the following: (a.) Please indicate whether the Veteran’s headaches are manifestations of his brain aneurysms and calcifications diagnosed in 2013. If the Veteran’s headache disability is separate and distinct from his brain aneurysms and calcifications, this should be made clear with a medical explanation as to how this is known. (b.) Notwithstanding the response to the question above, please indicate whether it is it at least as likely as not (50 percent or greater probability) that the brain aneurysms and calcifications diagnosed in 2013 had onset in, or are otherwise related to the Veteran’s period of active duty service, to include working in close proximity to cannon fire, and/or his presumed exposure to herbicides or contaminated rice paddy water in South Vietnam.. The examiner should consider the Veteran’s report of having experienced headaches during service and since that time, and presume as true that he entered service with no residuals of his pre-service brain hemorrhage. (c.) If the Veteran’s headache disability is a separate and distinct disease entity from the brain disabilities, please still indicate whether it is at least as likely as not (50 percent or greater probability) that the headache disability had onset in, or is otherwise related to service, to include working in close proximity to cannon fire, and/or his presumed exposure to herbicides or contaminated rice paddy water in South Vietnam. The examiner should consider the Veteran’s report of having experienced headaches during service and since that time, and presume as true that he entered service with no residuals of his pre-service brain hemorrhage. (d.) If the Veteran’s headache disability and brain disability are separate and distinct disease entities, please indicate whether one at least as likely as not causes or aggravates the other. All opinions should be supported by a medical explanation or rationale. If in the opinion of the reviewing clinician answers the questions above cannot be provided without an in-person or virtual interview or examination, such should be scheduled. 2. Obtain a medical opinion from a clinician other than the September 2020 VA examiner addressing the etiology of the Veteran’s ulcer disability. A copy of the claims file should be sent to, and reviewed by the reviewing clinician. Upon review of the file, the reviewing clinician should respond to each of the following: Is it at least as likely as not that the Veteran’s ulcer disability is caused or aggravated beyond its natural progression by his service-connected PTSD and/or his service-connected GERD with cricopharyngeal achalasia? All opinions should be supported by a medical explanation or rationale. If in the opinion of the reviewing clinician answers the questions above cannot be provided without an in-person or virtual interview or examination, such should be scheduled. 3. Readjudicate the appeal. If the benefits sought remain denied, issue the Veteran and his representative a supplemental statement of the case. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Bristow Williams, 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.