Citation Nr: 21011020 Decision Date: 02/26/21 Archive Date: 02/26/21 DOCKET NO. 20-17 259 DATE: February 26, 2021 ORDER Entitlement to service connection of an acquired psychiatric disorder, to include diagnoses of posttraumatic stress disorder (PTSD) and major depressive disorder, is granted. Entitlement to service connection of right upper extremity neuropathy is granted. Entitlement to service connection of left upper extremity neuropathy is granted. REMANDED Entitlement to service connection of congestive heart failure from non-ischemic cardiomyopathy with chronic atrial fibrillation, status-post left ventricular assistive device (LAVD), is remanded. Entitlement to service connection of stroke is remanded. FINDINGS OF FACT 1. The Veteran has an acquired psychiatric disorder, which is at least as likely as not related to his in-service experiences, as well as his various service-connected disabilities. 2. The Veteran has bilateral upper extremity neuropathy which is at least as likely as not related to his service-connected diabetes mellitus. CONCLUSIONS OF LAW 1. The criteria for service connection of an acquired psychiatric disorder are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 2. The criteria for service connection of right upper extremity neuropathy are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for service connection of left upper extremity neuropathy are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1964 to May 1966. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2019 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In December 2020, the Veteran testified before the undersigned Veterans Law Judge at a virtual hearing. A transcript of that hearing is of record. Service Connection The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. 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). Generally, establishing service connection requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). In addition, certain chronic diseases, including psychoses, may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Regardless of whether the condition is listed as “chronic,” a continuity of symptoms from the time of service is a factor to be considered in weighing the evidence of a claim. A disability may also be found service connected on a secondary basis by demonstrating that the disability is either (1) proximately due to or the result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310. 1. Entitlement to service connection of an acquired psychiatric disorder, diagnosed variously as posttraumatic stress disorder and major depressive disorder The Veteran seeks service connection of an acquired psychiatric disorder. The Board finds that the claim should be granted. As an initial matter, the Board recognizes that this appeal has actually come before it as two separate appeals: the first seeks service connection of PTSD, the second seeks service connection of major depressive disorder. The Court of Appeals for Veterans Claims (Court) has held that a claim for a psychiatric disability includes a claim for any psychiatric diagnosis which may or may be reasonably encompassed by his description of symptoms of that disability. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). In this respect, the Board has combined both claims into a single claim, encompassing all possible diagnoses which encompass his claimed symptoms. While service connection for an acquired psychiatric disorder other than PTSD follows the general laws and regulations for service connection, as discussed above, in order to establish entitlement to service connection for PTSD, the Veteran must show: (1) a diagnosis of PTSD in accordance with 38 C.F.R. § 4.125(a) (referencing the standards of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)); (2) a link, established by medical evidence, between current symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). In this matter, the Veteran has submitted multiple statements regarding stressors experienced during active service, particularly his confirmed service in the Republic of Vietnam, as a supply specialist. The Veteran was afforded a VA examination in December 2018. At that time, the examiner declined to diagnose PTSD, finding that his symptoms did not meet the DSM-5 criteria for such a diagnosis, although not explaining precisely which criteria were not met, rather simply finding that all criterion were deficient. Rather, the examiner found a present diagnosis of major depressive disorder. The examiner reviewed the available medical records and concluded that the Veteran’s major depressive disorder was not related to any specific incident of active service, rather attributing his major depressive disorder to his various other medical conditions, particularly his coronary condition. A review of the Veteran’s VA treatment records indicate that in April 2019, the Veteran presented for psychiatric care at a VA facility. Following an in-depth examination of the Veteran, to include his medical treatment history, the examiner gave a diagnosis of PTSD, as related to several witnessed incidents during active service, particularly incidents which occurred during his service on a transportation convoy. The examiner also confirmed a recurrent diagnosis of major depressive disorder. The evidence thereafter suggests ongoing treatment through VA facilities for both major depressive disorder and PTSD. The Veteran has also provided a May 2020 statement from his VA treating psychologist, reconfirming his diagnoses of both major depressive disorder and PTSD, which she attributed to, among other things, his distressing triggers from Vietnam. Concerning the PTSD diagnosis, the Board finds the 2019 and 2020 medical evidence and statements to be more persuasive in this matter than the 2018 examination. While the examination declined to diagnose PTSD, it was based upon a single interaction with the Veteran, who is admittedly (via his medical records) reticent to open up about the specifics of his traumatic experiences during active service. However, VA treating specialists thereafter found his reported stressors to be more than adequate to support a diagnosis of PTSD under the DSM-5 requirements. Further, even if the 2018 examination only found a present diagnosis of major depressive disorder, it clearly attributed that diagnosis to the Veteran’s other service-connected disabilities, particularly his coronary artery disease, implying a clear path to secondary service connection for symptoms attributable to that diagnosis. In sum, the Board is satisfied that the evidence suggests a presently diagnosed acquired psychiatric disability, which has been diagnosed to include features of PTSD and major depressive disorder, which is either directly related to the Veteran’s in-service stressor events, or caused/aggravated by his other service-connected disabilities. As such, the Board will afford the Veteran the benefit of the doubt and grant service connection for such an acquired psychiatric disorder, which encompasses both psychiatric claims. 2. Entitlement to service connection of right upper extremity neuropathy 3. Entitlement to service connection of left upper extremity neuropathy The Veteran seeks service connection of right and left upper extremity neuropathy, which he asserts is related to his diabetes mellitus. The Veteran has been granted service connection of lower extremity neuropathy, which has been clearly attributed to his service-connected diabetes mellitus. His upper extremity neuropathy, however, has been denied service connection because the examiner declined to give a confirmed diagnosis of neuropathy in the upper extremities. The Veteran was afforded a VA examination in 2018 which declined to diagnose neuropathy in the upper extremities, despite contemporary evidence of a possible neuropathic condition in the arms. Particularly, the examiner noted symptoms such as decreased reflexes in the biceps and triceps, and a neurological examination, conducted at the same time, found evidence of weakness in the left arm and hand (which was generally attributed to his stroke, however, was also noted to potentially have diabetic indications). Despite giving a diagnosis of lower extremity diabetic peripheral neuropathy, the examiner did not give an explanation for not providing a diagnosis in the upper extremities. Since the time of that examination, the Veteran’s available treatment records continue to document ongoing general diabetic neuropathy. He has also provided evidence in the form of testimony that he suffers from the same symptoms in both his legs and arms, particularly extreme bilateral numbness in the arms, nerve pains in the hands, as well as hair loss on the arms and legs. His spouse has testified that his upper extremity symptoms have followed the same progression as those in the lower extremities which have been attributed to his diabetic neuropathy by VA examiners. As a lay person, the Veteran is competent to provide testimony as to observable symptoms such as pain, numbness, and loss of hair. There is no indication based on the evidence of record, to include his hearing before the undersigned to find him less than credible in his testimony. Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007); see also Caluza v. Brown, 7 Vet. App. 498 (1995). In light of the evidence specific to this matter, and affording the Veteran the benefit of the doubt, the Board will grant service connection of bilateral upper extremity neuropathy as secondary to diabetes mellitus. In this respect, the evidence suggests a present diagnosis of that condition more than likely exists, particularly as his VA records continue to document general diabetic neuropathy, not just limited to his lower extremities, and he has provided competent and credible testimony as to symptoms clearly attributable to such a diagnosis. The evidence, to include his prior examinations and opinions also clearly attributes his neuropathic symptoms to his diabetes mellitus. As such, the Board is satisfied that the criteria for secondary service connection have been met and the claim is granted. REASONS FOR REMAND 1. Entitlement to service connection of congestive heart failure from non-ischemic cardiomyopathy with chronic atrial fibrillation, status-post left ventricular assistive device (LAVD), is remanded. 2. Entitlement to service connection of stroke is remanded. The Veteran seeks service connection of congestive heart failure from non-ischemic cardiomyopathy with chronic atrial fibrillation, which he has claimed is secondary to his service-connected diabetes mellitus. It is noted that he is also presently service-connected for non-obstructive coronary artery disease (previously evaluated as ischemic heart disease). Inasmuch as the Board regrets further delay in this matter, a remand is required in this matter to ensure complete development of this claim prior to final adjudication. Although the Veteran was afforded a VA examination and an etiology opinion given in January 2019, the Board finds that the opinion is inadequate to fully assess the claim. To the extent that the Veteran seeks service connection on a secondary basis, as noted above, secondary service connection requires consideration of both direct causation by a service-connected disability, as well as any potential aggravation by a service-connected disability. Although an opinion was given finding that the Veteran’s congestive heart failure sue to non-ischemic cardiomyopathy with atrial fibrillation pre-dated his diabetes diagnosis, and therefore could not be directly caused by it, there is no consideration given as to whether his cardiomyopathy has subsequently been aggravated beyond natural progression by his diabetes mellitus. Therefore, on remand, an addendum opinion should be obtained which addresses this question. Further because the claimed condition is coronary in nature, and the Veteran is already service connected for a separate heart condition (coronary artery disease), the Board would also request a secondary service connection opinion based on his other service-connected heart condition. Finally, to the extent that the evidence suggests a direct link between the Veteran’s atrial fibrillation and his claimed stroke and subsequent residuals, the Board must remand the stroke claim as inextricably intertwined with the cardiomyopathy claim. The matters are REMANDED for the following action: 1. Invite the Veteran to submit any additional evidence in support of his appeal. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s congestive heart failure due to cardiomyopathy with atrial fibrillation is at least as likely as not aggravated beyond its natural progression by his service-connected diabetes mellitus. The Board would also request an opinion from an appropriate clinician regarding whether the Veteran’s congestive heart failure due to cardiomyopathy with atrial fibrillation is at least as likely as not related to or proximately due to his service-connected coronary artery disease; or in the alternative, aggravated beyond its natural progression by his service-connected coronary artery disease. 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. B.T. KNOPE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Pryce, Counsel