Citation Nr: 21012497 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 14-38 857 DATE: March 4, 2021 ORDER Entitlement to service connection for sarcoidosis is granted. REMANDED Entitlement to service connection for a heart disability is remanded. Entitlement to service connection for bilateral hearing loss disability is remanded. Entitlement to service connection for tinnitus is remanded. FINDING OF FACT Resolving reasonable doubt in the Veteran’s favor, his sarcoidosis is etiologically related to his active service. CONCLUSION OF LAW The criteria for entitlement to service connection for sarcoidosis have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active air service from June 1990 to June 2000. This case comes before the Board of Veterans’ Appeals (Board) on appeal from February 2013 and January 2014 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that the Veteran testified before a Veterans Law Judge (VLJ) at a hearing in October 2016. A transcript of that hearing has been associated with the claims file. The VLJ who held the October 2016 hearing is no longer employed at the Board. In September 2020, the Board notified the Veteran that he had the right to testify at a new hearing before another VLJ who would participate in the final determination of his claim. 38 U.S.C. § 7107(c) (2018); 38 C.F.R. § 20.604 (2019). The Veteran did not respond within 30 days of the September 2020 notification letter. Therefore, the Board considers the opportunity for a new hearing declined, and will proceed with adjudication of the issues on appeal. Service Connection – Sarcoidosis The Veteran asserts that his sarcoidosis is casually related to his active service. Specifically, the Veteran asserts that his symptoms began during his active service but were misdiagnosed by the military physicians who evaluated his condition. At the outset, the Board notes that the Veteran’s service treatment records (STRs) are absent of any diagnosis of sarcoidosis. However, the Veteran’s STRs do reveal that in June 1992, the Veteran was assessed as having possible atrial enlargement, non-specific intraventricular block, and possible left ventricular hypertrophy. Additionally, in October 1993, the Veteran was assessed as having atypical chest discomfort and atypical chest pain. In January 2013, the Veteran was treated for complaints of weight loss and dyspnea. At that time, a VA physician, Dr. N.D. assessed that the Veteran had pulmonary sarcoidosis. Subsequently, during an October 2013 VA examination, the Veteran was assessed as having cardiac arrythmia. In a February 2014 private treatment note, the Veteran was noted as having a history of an enlarged heart. In September 2014, the Veteran was afforded a VA examination for respiratory conditions. At that time, the Veteran reported that his symptoms included cough, fatigue, shortness of breath, sweats, and lack of sleep. The Veteran also reported that his diagnosis of sarcoidosis had been misdiagnosed from 2008 to 2012. The VA examiner noted the Veteran’s current diagnosis of sarcoidosis. However, the VA examiner opined that the Veteran’s sarcoidosis was less likely than not incurred in or caused by his service. The VA examiner reasoned that there was no evidence of sarcoidosis or pulmonary complaints in the Veteran’s STRs, and as such, there could be no objective association made with his diagnosis. In a November 2016 private medical opinion, Dr. C.M.B. stated that the Veteran’s sarcoidosis was present during his time on active duty, and that his condition was linked to his active duty service. Dr. C.M.B. noted that a majority, if not all, of the Veteran’s symptoms (i.e. chest pain, enlarged heart and arrythmia, coughing, wheezing, and fever) were all diagnosed during his service, or present in his records. Dr. C.M.B. also noted that his conclusion was further supported by the natural progression and later stages of the disease which caused lymph node enlargement and the Veteran’s near fatal experience that led to his initial diagnosis of sarcoidosis. In a December 2016 private medical opinion, Dr. K.W. stated that it was likely that the Veteran contracted sarcoidosis while on active duty. Dr. K.W. further assessed that the majority of the Veteran’s symptoms, to include enlargement of the heart, arrhythmias, chest pain, lung problems, cough, wheezing, and night sweats, were likely early manifestations of the disease process. In June 2019, a VA physician opined that it was less likely than not that the Veteran’s sarcoidosis was first manifested in, incurred in, or caused by an in-service injury or event. The VA examiner reasoned that the Veteran’s records from 1996 to 2000 showed multiple episodes of sinusitis with complaint of cough, headaches, and a runny nose, and one EKG which showed nonspecific intraventricular conduction delay. The VA examiner stated that from 2001 to 2013 the Veteran had minimal complaint of respiratory symptoms, and that prior to his diagnosis of sarcoidosis he did not receive any immunosuppressive treatment or have many respiratory complaints. The VA examiner also stated that there was no objective evidence that the Veteran’s symptoms, as indicated by Dr. C.M.B, were associated with sarcoidosis as many of the symptoms resolved without immunosuppressive, which was the main treatment for sarcoidosis. The VA examiner also stated that the Veteran’s 2018 MRI did not support a diagnosis of cardiac sarcoidosis, and his symptoms of coughing, wheezing, and night sweats were improved after being treated with antibiotics for sinusitis. The VA examiner further noted that the Veteran’s Ear, Nose, and Throat (ENT) provider did not associate his chronic sinusitis with sarcoidosis. In an October 2019 pulmonary clinic note, the Veteran was noted as complaining of worsening shortness of breath and increased wheezing. At that time, it was noted that the Veteran used Prednisone and inhalers. In November 2019, Dr. K.W. opined that it was more likely than not that the Veteran contracted sarcoidosis while on active duty, and that the symptoms noted in his STRs were consistent with, and likely early manifestations of, sarcoidosis. The Board initially finds that the September 2014 VA examination is inadequate for adjudication purposes. In that regard, the VA examiner’s negative opinion primarily relied on the absence of evidence in the Veteran’s STRs. Additionally, the VA examiner failed to accurately report that the Veteran’s initial diagnosis of sarcoidosis was in January 2013. As the opinion is inadequate, it cannot serve as the basis for a denial. The Board also notes that the December 2016 private medical opinion, from Dr. K.W., is of low probative value. In that regard, Dr. K.W.’s use of the word “likely” is speculative language, even though the rationale was well supported. See Bostain v. West, 11 Vet. App. 124, 127 (1998). In contrast, the Board finds that the November 2016, June 2019, and November 2019 medical opinions, both VA and private, are adequate for adjudication purposes. In that regard, those physicians, thoroughly reviewed and discussed the relevant evidence, considered the contentions of the Veteran, and provided thorough supporting rationale for the conclusions reached. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board acknowledges that the June 2019 VA medical opinion is against a finding of an etiological link between the Veteran’s diagnosis of sarcoidosis and his active service. However, the Board finds that the contrasting medical opinions provided in November 2016 and November 2019 render the evidence in equipoise as to whether the Veteran’s sarcoidosis is etiologically related to his active service. Accordingly, resolving reasonable doubt in the Veteran’s favor, the evidence for and against the claim is in equipoise and entitlement to service connection for sarcoidosis is warranted. 38 U.S.C. § 1151 (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND Service Connection – Heart Disability The Veterans STRs reveal that in June 1992 he was noted as having possible atrial enlargement and left ventricular hypertrophy. Subsequently, in another June 1992 treatment note, the Veteran was assessed as having a heart murmur and needing an echocardiogram. In a September 1993 treatment note, the Veteran was assessed as having atypical chest discomfort. In October 1993, the Veteran was noted as having atypical chest pain and a radiology consultation was requested. In October 2013, the Veteran was afforded a VA examination for heart conditions. At that time, the VA examiner found that there was no diagnosis of a heart condition and that continuous medication was not required to control the Veteran’s heart condition. However, the VA examiner did note that the Veteran had cardiac arrythmia. In September 2014, the Veteran was afforded another VA examination for heart conditions. At that time, the VA examiner noted that the Veteran had a diagnosis of ischemic heart disease, but that continuous medication was not required to control his heart condition. The VA examiner opined that there was no diagnosis because there was no pathology to render a diagnosis. Since those VA examinations, the Veteran’s treatment records revealed notations of a history of an enlarged heart, a soft systolic murmur, and continuous usage of the medication, Amlodipine, for his heart. The Board is unclear as to whether the previously mentioned conditions are solely attributable to the Veteran’s sarcoidosis or distinguishable as separate ratable diagnoses. Consequently, the Veteran should be afforded a new VA examination to determine the nature and etiology of any currently present heart disability and whether that disability is a symptom of the Veteran’s sarcoidosis, or is a separate diagnosis that was incurred during his active service or caused or aggravated by his sarcoidosis. Service Connection – Bilateral Hearing Loss Disability and Tinnitus The Veteran asserts that his bilateral hearing loss disability and tinnitus are the result of exposure to hazardous noise during his active service. The Veteran’s STRs reveal that on a few occasions he was reported as having right ear pain, irritation, and fluid in association with his sinus and upper respiratory infections (URI). The Veteran’s STRs otherwise reveal normal hearing. In a February 2014 primary care note, the Veteran was noted as having changes in his hearing. Subsequently, in a May 2014 internal medicine note, the Veteran reported having mild ringing in his ears for years. At that time, the Veteran’s wife also stated that he had to watch the television louder and should be evaluated for possible hearing loss. During a July 2014 audiology consultation, the Veteran reported longstanding bilateral tinnitus and bilateral hearing loss. At that time, the Veteran’s puretone results revealed that his bilateral hearing was withing normal limits. However, the Board notes that the Veteran’s right ear word recognition score was 92 percent. Additionally, the Audiologist commented that the Veteran was scheduled for a progressive tinnitus management program. During his October 2016 Board hearing, the Veteran testified that he noticed slight bilateral hearing loss and tinnitus during his active service. In February 2018 progress note, the Veteran was noted as having bilateral hearing loss, tinnitus, ear pain, and vertigo. The Veteran has not yet been afforded a VA examination to determine the nature and etiology of any currently present bilateral hearing loss or tinnitus disabilities. As such, based on the foregoing, an examination must be accomplished on remand. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA cardiology examination to determine the nature and etiology of any currently present heart disability. The claims file must be made available to and reviewed by the examiner. Any indicated studies must be performed. Based on the examination of the Veteran and a review of the record, the examiner must first identify all cardiac disabilities present during the pendency of the appeal, or approximate thereto. Then, for each disability identified, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that such disability had its onset during the Veteran’s active service, or is otherwise etiologically related to such service. The examiner must also provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any identified heart disability was caused or aggravated by the Veteran’s sarcoidosis. A complete and detailed rationale for all opinions expressed must be provided. 2. Schedule the Veteran for a VA audiology evaluation to determine the nature and etiology of any currently present bilateral hearing loss disability and tinnitus. The claims file must be made available to and reviewed by the examiner. Based on the examination of the Veteran and a review of the record, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any currently present bilateral hearing loss disability and/or tinnitus is etiologically related to the Veteran’s active service. In forming the opinion, the examiner must consider the Veteran’s lay statements regarding the onset and continuity of his symptoms. A complete and detailed rationale must be provided for all opinions expressed. 3. Then, readjudicate the claims on appeal. If any decision is adverse to the Veteran, issue a supplemental statement of the case and allow appropriate opportunity for a response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Byrd, 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.