Citation Nr: 21013014 Decision Date: 03/08/21 Archive Date: 03/08/21 DOCKET NO. 13-22 382 DATE: March 8, 2021 ORDER Entitlement to service connection for temporary blindness is denied. Entitlement to service connection for a thyroid disorder is denied. Entitlement to service connection for coronary artery disease is granted. Entitlement to service connection for internal bleeding is granted. Entitlement to service connection for anemia is granted. FINDINGS OF FACT 1. The most probative evidence fails to demonstrate that the Veteran has experienced a clinically significant disability manifested as temporary blindness during the appellate period, and his reported symptom has not resulted in a functional impairment in earning capacity during the appellate period. 2. The most probative evidence establishes that the Veteran’s thyroid disability was not incurred in or is otherwise etiologically related to his active duty service, and this disability was not caused or aggravated by the Veteran’s service-connected posttraumatic stress disorder (PTSD) or his right radical nephrectomy. 3. The evidence is in relative equipoise as to whether the Veteran’s coronary artery disease is related to his obesity, which has been determined to have developed as a result of the Veteran’s service-connected left knee disability. 4. The most probative evidence establishes that the Veteran’s internal bleeding was caused by his November 2000 gastric bypass surgery, which was conducted to treat the Veteran’s obesity, which has been determined to have developed as a result of the Veteran’s service-connected left knee disability. 5. The most probative evidence establishes that the Veteran’s anemia was caused by his gastric bleeding, secondary to his November 2000 gastric bypass surgery, which was conducted to treat the Veteran’s obesity, which has been determined to have developed as a result of the Veteran’s service-connected left knee disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for temporary blindness have not been met. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. 2. The criteria for entitlement to service connection for a thyroid disorder have not been met. 38 U.S.C. § 1131; 38 C.F.R. § 3.303, 3.310. 3. The criteria for entitlement to service connection for coronary artery disease have been met. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.310. 4. The criteria for entitlement to service connection for internal bleeding have been met. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.310. 5. The criteria for entitlement to service connection for anemia have been met. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.310. REFERRED The issues of entitlement to service connection for bronchitis and gastroesophageal reflux disease were raised at the December 2017 Board of Veterans’ Appeals (Board) hearing and in a September 2020 private medical opinion, respectively, and are referred to the Agency of Original Jurisdiction (AOJ) for appropriate action, to include to include forwarding VA’s standardized claim form to the Veteran. 38 C.F.R. § 20.904 (formerly 19.9). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1975 to June 1977. These matters come before the Board on appeal from a January 2010 rating decision issued by a Regional Office (RO) of the United States Department of Veterans Affairs (VA). The Veteran presented sworn testimony before the undersigned Veterans Law Judge at a December 2017 videoconference hearing. A copy of the hearing transcript has been associated with the Veteran’s electronic claims file. The Board notes that additional VA-generated evidence has been received since these matters were last adjudicated by the RO in the November 2020 Supplemental Statement of the Case. However, this evidence is irrelevant to the current matters, and the Board may proceed with its appellate consideration. 38 C.F.R. § 20.1305 (formerly 20.1304). Additionally, the Veteran has several claims that are awaiting the scheduling of a Board hearing. See March 2020 VA form 9. These claims shall be addressed in a future Board decision, if otherwise in order. Under 38 U.S.C. § 7104, Board decisions must be based on the entire record, with consideration of all the evidence. The law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122, 128-29 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence within the period on appeal and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake, supra. Service Connection Generally, to establish service connection, a veteran must show: (1) a current disability; (2) an in-service incurrence of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred during service, the so-called “nexus” requirement. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). All elements must be satisfied before service connection may be achieved. Additionally, service connection may be achieved if any applicable presumptive service connection regulations apply to the Veteran’s circumstances or when a claimed disability is shown to be proximately due to, the result of, or aggravated by a service-connected disability. As discussed further below, the Veteran has alleged that several of the claims on appeal developed as a result of obesity caused by his service-connected disabilities. The United States Court of Appeals for Veterans Claims (Court) has held that “there is currently no provision in the rating schedule to compensate for obesity.” Marcelino v. Shulkin, 29 Vet. App. 155, 158 (2018). Indeed, in a precedential opinion, VA’s General Counsel concluded that obesity per se is not a disease or injury for purposes of 38 U.S.C. §§ 1110 and 1131, and may not be service connected on a direct basis. VAOPGCPREC 1-2017. However, the General Counsel also recognized that obesity may act as an “intermediate step” between a service-connected disability and a current disability that may be service connected on a secondary basis under 38 C.F.R. § 3.310(a). See id. at 2. The first inquiry is whether the service-connected disability caused the veteran to become obese. If so, then the adjudicator must address whether the obesity (as a result of the service-connected disability) was a substantial factor in causing the nonservice-connected disability, and whether the nonservice-connected disability would not have occurred but for the obesity. See id. at 9-10. Recently, in Walsh v. Wilkie, 32 Vet. App. 300 (2020), the Court extended the rationale from the General Counsel’s opinion and concluded that obesity as an “intermediate step” in a causal chain for service connection can be established on either a causal or aggravation basis. In the present matter, the Veteran submitted a private medical opinion from February 2017 concluding, in relevant part, that the Veteran’s obesity was caused by his service-connected left knee disability. The private physician noted that the Veteran entered service at 195 pounds, and following an in-service left knee injury, his weight was 250 pounds at service discharge, and has remained a chronic condition since service separation. Since then, additional medical opinions have been received which are conflicting on this point. A July 2020 VA examiner declined to link the Veteran’s obesity to his service-connected left knee disability, opining that “obesity is not solely caused by inactivity [due to physical restrictions caused by the Veteran’s left knee disability],” stating further that “a poor diet with a calorie excess is needed for obesity despite limited exercise.” In September 2020, the Veteran submitted an additional private medical opinion linking the Veteran’s obesity to his service-connected left knee disability. The private physician assistant argued that the Veteran’s left knee disability prevented him from exercising, and citing medical literature, she opined that “an individual’s inability to exercise is a primary cause of obesity in most patients.” She further noted that the Veteran’s diet should also be taken into consideration, and cited a private medical opinion from psychologist JV, dated in December 2015, which referred the Veteran to a nutritionist to develop a dietary plan to deal with problems of overeating as a compensatory mechanism related to his service-connected PTSD. In October 2020, VA obtained an addendum opinion concluding that the Veteran’s obesity was less likely than not caused by his service-connected left knee disability. The VA examiner focused his opinion on the causal relationship between the Veteran’s obesity and his 2001 arthroplasty, without regard to the in-service weight gain after the Veteran’s in-service left knee injury, as highlighted by the February 2017 private opinion. The VA examiner refuted the September 2020 private opinion, noting that recent VA treatment records showed that the Veteran was participating in water exercises despite his orthopedic disabilities. The VA examiner also noted that some of the literature cited by the September 2020 private physician assistant did not necessarily support her opinion, when applied to the Veteran’s specific medical history and/or metrics. As the finder of fact, it is the Board’s duty to assess the credibility and weight of conflicting evidence. See Washington v. Nicholson, 19 Vet. App. 362, 367-68 (2005). In the present matter, the Board has reviewed the conflicting medical opinions and finds their probative value to be in relative equipoise on the issue of whether the Veteran’s service-connected left knee disability has caused or aggravated the Veteran’s obesity. Each opinion was issued by a medical professional and supported by an explanatory rationale based on record evidence. The opinions in substantial conflict, mainly the September 2020 private opinion and the October 2020 VA medical opinion, each relied on cherry-picking of the evidence to support their stated opinions. As the conflicting evidence is in relative equipoise, reasonable doubt must be resolved in the Veteran’s favor. See 38 C.F.R. § 3.102. Accordingly, the Board concludes that the Veteran’s service-connected left knee disability caused or aggravated the Veteran’s obesity. This factual determination will be applied to the applicable claims on appeal further below. 1. Entitlement to service connection for temporary blindness is denied. The Veteran seeks entitlement to service connection for temporary blindness. In several VA mental health records, and at the July 2020 VA eye examination, the Veteran reported that he experiences temporary blindness during episodes of panic attacks. The Board notes that the Veteran’s VA treatment records document the presence of a refractive error in both eyes, and an August 2012 VA optical record contains a single reference to bilateral nuclear sclerotic cataracts. In Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009), the Court cautioned VA that a veteran’s claim should not be limited to consideration of a specific diagnosis where the pleadings and evidence suggest a claim of broader scope. However, after a full review of the record, it is clear from the Veteran’s various statements and lay reports that he is only intending to seek service connection for the temporary blindness manifested during his panic attacks. Neither the Veteran nor his attorney has ever indicated that the Veteran was seeking service connection for a broader omnipresent visual disability, and such a claim has not been reasonably raised by the record. Despite the undersigned noting that temporary blindness was a claim for discussion at the December 2017 Board hearing, the Veteran did not offer any testimony regarding this disability and the Veteran’s attorney did not question the Veteran regarding this claim. In light of the above, the Board shall only consider this claim based on the symptom specifically alleged by the Veteran. Whether service connection is claimed on direct, presumptive, or any other basis, a necessary element for establishing such a claim is the existence of a current disability during the appellate period. See Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997) (holding that section 1131 requires the existence of a present disability for VA compensation purposes); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). The presence of a disability at the time of filing of a claim or during its pendency warrants a finding that the current disability requirement has been met, even if the disability resolves prior to the Board’s adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); see also Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013) (recent diagnoses predating filing of claim are relevant evidence in determining whether a current disability existed at the time the claim was filed or during its pendency). Here, the Veteran’s service treatment records are negative for visual complaints. At the June 1977 separation examination, the Veteran’s eyes were found to be clinically normal and his distant vision was 20/20 in the right eye and 20/30 in the left eye. The Veteran passed color vision testing in both eyes. There was no indication that the Veteran experienced any temporary blindness during his active duty service. As noted above, the Veteran reported temporary blindness during panic attacks to his VA mental health practitioners. There was a concern that this symptom may be the result of brain ischemia, however magnetic resonance imaging of the brain and computed tomography (CT) of the head were both normal. See February 2009 VA treatment records; December 2008 CT results. In April 2015, the Veteran reported occasional aura symptoms followed by transient blindness or flashes of vision. The physician noted the reports of ocular symptoms and questioned whether they could be the result of retinal migraine, aura without migraine, or amaurosis fugax. The physician did not render a clinical diagnosis. In fact, a review of the record reveals that none of the Veteran’s treating VA practitioners ever diagnosed the Veteran with a clinically significant visual disability manifested by episodes of temporary blindness occurring during panic attacks. The Veteran is competent to report symptoms capable of observation through the senses, such as visual disturbances, and his lay reports are credible, as they have been consistent over time. Nevertheless, the Veteran is not competent to diagnose his symptoms or opine on the etiology of his symptoms, as this requires medical expertise and training, as well as the use of diagnostic testing. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Thus, the Veteran’s lay reports are not probative on the existence of a current disability for VA compensation purposes. The Veteran was afforded a VA optometry examination in July 2020 to assess the severity and nature of his claimed vision disability. The VA examiner documented the Veteran’s lay reports that in 2000 he began experiencing panic attacks manifesting as temporary blindness lasting up to 45 minutes. The Veteran’s distant and reading vision could be corrected to 20/20 bilaterally. Pupils were round, reactive to light, and no afferent pupillary defect was detected. The VA examiner found no evidence of anatomical loss, light perception only, extremely poor vision, or blindness in either eye. Slit lamp, external eye exam, and fundus exam were normal bilaterally. No visual field defects were noted. The VA examiner concluded there were no findings to support a diagnosis for the Veteran’s reported temporary blindness. The July 2020 VA examiner stated that no abnormal physical ocular findings were found as an etiology to the Veteran’s reported temporary blindness, and the VA examiner concluded that the Veteran did not have a visual impairment. All objective testing was negative for a current bilateral eye disability manifested by temporary blindness. The Veteran’s VA treatment records contain no diagnosis for the Veteran’s reports of temporary blindness during panic attacks. As the Veteran’s reported visual disturbances have not resulted in a clinically significant diagnosis within the appellate period, the current disability prong of a service connection claim has not been satisfied. Historically, a symptom, alone, without a diagnosed or identifiable underlying malady, was not sufficient to establish a current disability for VA compensation purposes. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999). However, in Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), the United States Court of Appeals for the Federal Circuit rejected such a theory, holding that pain (or other symptoms) can constitute a current disability under 38 U.S.C. § 1110 (and § 1131), so long as it results in functional impairment of earning capacity. Here, the Veteran has not submitted any probative evidence establishing that his reported temporary blindness during panic attacks has resulted in a functional impairment which limited his earning capacity. At the July 2020 VA examination, the Veteran reported that he has to stop work or pull off the road during his episodes of temporary blindness. The record shows that the Veteran has been employed by VA and there is no evidence that his reported visual disturbances impacted his employment in any way that resulted in a reduction of earning capacity or diminution in pay. The evidence does not support the conclusion that the Veteran’s reported symptom results in a current disability under Saunders. In light of the above analysis, the Board finds that the Veteran has not experienced a disability manifested by temporary blindness sufficient for VA compensation purposes during the period on appeal. In the absence of a current disability, the Veteran’s appeal seeking entitlement to service connection for temporary blindness must be denied. 2. Entitlement to service connection for a thyroid disorder is denied. The Veteran seeks entitlement to service connection for a thyroid disorder. At the December 2017 Board hearing, he alleged that this disability was secondary to his service-connected PTSD or his service-connected right radical nephrectomy under 38 C.F.R. § 3.310. In the May 2018 remand decision, the Board also raised the prospects of direct service connection when it asked that a VA examiner opine on whether the Veteran’s claimed thyroid disability began during his active duty service. Following a complete review of the record, the evidence preponderates against the Veteran’s claim under all applicable theories of entitlement, as explained in the analysis below. At the December 2017 Board hearing, the Veteran testified that his VA treatment providers noted an issue with his thyroid stimulating hormone and diagnosed him with hypothyroidism. VA treatment records from February 2009 confirm that a diagnosis of hypothyroidism was issued during the appellate period. Regarding in-service incurrence, the Veteran’s service treatment records are entirely negative for complaints of thyroid-related symptoms or a clinical diagnosis of any thyroid abnormalities. The Veteran’s June 1977 separation examination indicates that the Veteran’s endocrine system was determined to be clinically normal. There is no probative evidence establishing that the Veteran experienced a thyroid disability during his active duty service. The Veteran attended a VA examination in July 2020 to assess the nature and severity of his claimed thyroid disability. The VA examiner noted a historical diagnosis of hypothyroidism. It was noted that the Veteran discontinued medication at the time of his gastric bypass surgery. The VA examiner found no evidence of residual endocrine dysfunction or any findings, signs, or symptoms attributable to a thyroid, hyperthyroid, or hypothyroid condition. The VA examiner declined to link the Veteran’s thyroid disability to his active duty service, correctly noting there was no evidence of a thyroid condition in the Veteran’s service treatment records. In fact, this condition did not begin until more than 20 years following the Veteran’s separation from service. This medical opinion is sufficient to resolve the direct service connection contention regarding the Veteran’s claim, as it was based on an accurate factual premise. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The July 2020 VA examiner’s medical nexus opinions addressing whether the Veteran’s thyroid condition is secondary to his service-connected right radical nephrectomy are inadequate for adjudicative purposes. The VA examiner denied a causal or aggravating relationship on the basis that the Veteran’s thyroid disability was present prior to the Veteran’s nephrectomy. However, in Frost v. Shulkin, 29 Vet. App. 131, 136-39 (2017), the Court held that 38 C.F.R. § 3.310(a) did not contain a temporal requirement excluding secondary service connection in situations where the secondary condition was incurred prior to the grant of service connection for, or diagnosis of, the primary condition. Moreover, the VA examiner did not address whether the Veteran’s right radical nephrectomy resulted in any incremental increase in the severity of the Veteran’s thyroid disability—any additional impairment of earning capacity, as described in Ward v. Wilkie, 31 Vet. App. 233 (2019). For these reasons, the July 2020 VA medical opinion addressing the Veteran’s secondary service connection contentions is not probative. The Veteran has submitted a September 2020 private medical opinion linking the Veteran’s thyroid disability to alcohol abuse precipitated by his service-connected PTSD. The private physician assistant stated that “[the Veteran’s] medical records shows that he started to suffer from thyroid dysfunction in late 1998 that has progressively worsened over time. His records also show that he has been struggling with alcohol addition since his time in service, which reportedly is linked to his service-connected mental health disorder through compensatory mechanisms.” The private physician assistant stated that it was well-known that overconsumption of alcohol affects thyroid functioning. Relying on cited medical literature, the private physician assistant opined that alcohol causes direct cellular toxicity on thyroid cells producing long-lasting or even permanent thyroid suppression, and the Veteran’s hyperthyroid condition was at least as likely as not secondarily linked to his service-connected PTSD, which resulted in chronic alcohol use. In October 2020, the RO obtained an addendum VA medical opinion from an appropriate VA examiner addressing whether the Veteran’s thyroid disability was secondary to his service-connected PTSD or his right radical nephrectomy. The VA examiner explained that the Veteran did not currently suffer from hyperthyroidism. In relevant part, the VA examiner explained: There is no current hyperthyroidism. The disease process which most likely caused the historic excess is common in the general population. Veteran’s presentation is unusual only because it is progressing so slowly. From 20 Oct 2000 through 26 Jun 2012, Veteran had suppressed levels of Thyroid Stimulating Hormone. The degree of suppression was most impressive early on (0.14-0.37 in 2001-2002) and became less severe 2008-2012 (0.284-0.479). Since 19 Feb 2013, the Thyroid Stimulating Hormone has been normal (0.552-0.738) (NORMAL RANGE IS 0.5-5.0). He never had symptoms of hyperthyroidism, because his concentration of Thyroid [Stimulating] Hormone was always normal. The most likely explanation, as described by endocrinologist in 2001, is Hashimoto’s Thyroiditis. Hashimoto’s is an autoimmune disease, which is the most common cause of thyroid dysfunction. In addition to producing Thyroid [Stimulating] Hormone, the thyroid stores a large amount of the hormone. Initially, the antibodies attack the thyroid, causing preformed Thyroid [Stimulating] Hormone to leak into the circulation. Due to this leak, the amount of thyroid needing to be secreted intentionally by the thyroid is reduced—less stimulation (and [Thyroid Stimulating Hormone]) is needed. As the disease progresses, the supply of preformed hormone becomes depleted and more stimulation is required. In most cases, the antibodies eventually destroy the thyroid’s production capacity. Eventually, the patient requires supplementation with levothyroxine. In most cases, this progresses much more rapidly. We can hope that the ability of the [Veteran’s] thyroid to respond to stimulation will remain intact for many more years. In November 2020, a further addendum VA medical opinion was obtained and reiterated that the Veteran’s lab results did not show hyperthyroidism at the July 2020 VA examination and there was no medical evidence showing a thyroid condition that has worsened over time. In reviewing the competing medical evidence, the Board affords more evidentiary weight to the cumulative October 2020 and November 2020 VA medical opinions over the factually inaccurate September 2020 private medical opinion. As explained by the October 2020 VA examiner, the private physician assistant’s conclusion that the Veteran’s thyroid dysfunction has worsened over time is not supported by the Veteran’s medical records. Lab results from 2001 to 2012 show thyroid stimulating hormone in the hyperthyroid level trending towards the normal range. Data since 2013 has shown a normal thyroid stimulating hormone level. Thus, the results of the Veteran’s serologic testing over time do not demonstrate permanent or long-lasting thyroid suppression as opined by the September 2020 private physician assistant. The October 2020 VA examiner thoroughly explained why the September 2020 medical opinion was factually inaccurate based on the serologic levels of thyroid stimulating hormone documented in the Veteran’s medical records. Factually inaccurate medical opinions are entitled to no probative value. Reonal, supra. Regarding the Veteran’s contention that his thyroid disability may be the result of his service-connected PTSD or his nephrectomy, the Veteran is not competent to render a medical nexus opinion, as he is without the medical training or expertise to opine on complex medical matters. See Jandreau, supra. Moreover, the October 2020 VA examiner has refuted the idea that the Veteran’s PTSD or nephrectomy have caused his thyroid disorder. Instead, the October 2020 VA examiner thoroughly explained that the Veteran’s thyroid disability was the result of an autoimmune response known as Hashimoto’s thyroiditis, which is common in the general population. The VA examiner explained that the body’s antibodies attack the thyroid eventually leading to a decrease in the production of thyroid stimulating hormone. The VA examiner explained that this autoimmune response was the true cause of the Veteran’s disability; thus ruling out PTSD or nephrectomy as potential causes. Regarding aggravation, both the October 2020 and November 2020 VA examiners explained that the Veteran’s thyroid disability has not worsened over time. In fact, the October 2020 VA examiner stated that the Veteran’s presentation was unusual given how slowly the condition has progressed. Thus, the VA examiners have implied that nothing is aggravating the severity of the Veteran’s thyroid disability beyond its normal progression. To the contrary, the Veteran’s condition is progressing at a slower rate than normally observed in similarly situated individuals. Accordingly, the October 2020 and November 2020 VA medical opinions have tacitly explained that no phenomenon, including the Veteran’s PTSD and nephrectomy, have resulted in any incremental increase in the severity of the Veteran’s thyroid disability. Ward, supra. The Board finds the cumulative October 2020 and November 2020 VA medical opinions to be the most probative evidence of record on the issue of secondary service connection. These medical opinions thoroughly explained the cause of the Veteran’s disability and rejected the notion that the Veteran’s condition has been aggravated beyond its normal progression. Collectively, these medical opinions were factually accurate, fully articulated, and supported by sound reasoning for the proffered conclusions. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In sum, the most probative evidence of record has determined that the Veteran’s thyroid disability was not incurred during active duty service and is not secondary to his service-connected PTSD or right radical nephrectomy. The claim fails on all theories of entitlement asserted by the Veteran or reasonably raised by the record. Accordingly, the Veteran’s appeal seeking service connection for a thyroid disability must be denied. 3. Entitlement to service connection for coronary artery disease is granted. The Veteran seeks entitlement to service connection for coronary artery disease as secondary to his service-connected left knee disability and/or secondary to his service-connected PTSD. Specifically, he alleges that his left knee disability limited his physical activity, which resulted in the development of obesity, which in turn caused his coronary artery disease. Alternatively, he argues that his service-connected PTSD was manifested by a coping mechanism of overeating; and this symptom along with side effects from his psychotropic medication, resulted in obesity, which in turn caused his coronary artery disease. The Veteran attended a VA examination in July 2020 to assess the nature and severity of his claimed coronary artery disease. The VA examiner noted a historical diagnosis of coronary artery disease but stated that the condition has “stayed the same” over time. The VA examiner declined to link the Veteran’s coronary artery disease to obesity caused by his service-connected left knee disability. As discussed supra, she noted that obesity is not solely caused by restricted activity and is also due to excessive caloric intake (caused by poor diet with excess calories, sugar, and saturated fat) which would have been unaffected by his service-connected left knee disability. The Board finds this rationale to be insufficient, as the Board has already factually determined that the Veteran’s left knee disability was the cause of his morbid obesity. The Veteran submitted a September 2020 private medical opinion linking the Veteran’s coronary artery disease to obesity caused by his service-connected left knee disability and compensatory eating patterns due to his service-connected PTSD. The physician assistant noted that obesity played a role in the development of hyperlipidemia, which is a primary risk factor for the development of coronary artery disease. The physician assistant stated that the Veteran did not experience hypertension at the time of his stent placement, thus lending credence that other factors—such as obesity causing hyperlipidemia—greatly contributed to his myocardial infarction and coronary artery disease diagnosis. The record contains an October 2020 VA medical opinion addressing whether the Veteran’s coronary artery disease is secondary to the Veteran’s service-connected PTSD or right radical nephrectomy. The VA examiner stated that obesity in an individual with an otherwise healthy lifestyle is a minor risk factor for coronary artery disease when compared to an extensive smoking history or history of cocaine abuse. It appears that the VA examiner found the Veteran’s history of smoking two packs of cigarettes per day for 20 years and his history of cocaine abuse to be greater risk factors for the development of coronary artery disease than the Veteran’s obesity. The VA examiner rejected any aggravation argument, stating there was no abnormally rapid progression of the Veteran’s coronary artery disease. A final VA medical opinion was obtained in November 2020. The VA examiner stated that obesity does not cause coronary artery disease, as this condition is due to underlying atherosclerosis of the coronary arteries causing ischemia. The VA examiner opined that the Veteran was at an increased risk for atherosclerosis due to hypertension, high cholesterol, cigarette smoking, and cocaine abuse. Weighing the competing medical opinions, the Board finds them to be in relative equipoise. Each health professional correctly evaluated the Veteran’s specific medical history and issued a medical opinion supported by a known medical pathology that could equally apply to the Veteran’s specific circumstances. It is true that the Veteran has a history of obesity caused by his service-connected left knee disability, a private medical opinion has cautioned that the Veteran’s mental health disability results in overeating, and the Veteran has an extensive history of hyperlipidemia, tobacco abuse, and polysubstance abuse, to include the use of cocaine. Thus, with the evidence in relative equipoise, the Board must resolve reasonable doubt in the Veteran’s favor, and thereby concludes that the Veteran’s coronary artery disease is caused by obesity resulting from his service-connected left knee disability, as posited by the September 2020 private physician assistant. See 38 C.F.R. § 3.102. In light of the above analysis, the requisite elements of service connection have been satisfied. The resolution of reasonable doubt has led to the conclusion that the Veteran’s coronary artery disease is secondary to the Veteran’s service-connected left knee disability, utilizing obesity as an intermediary step. Accordingly, the Veteran’s appeal seeking service connection for coronary artery disease is granted. Given this favorable outcome, there is no basis upon which to further consider any other theories of entitlement raised by the Veteran or the evidence of record. 4. Entitlement to service connection for internal bleeding is granted. The Veteran seeks entitlement to service connection for internal bleeding, claimed as originally developed during his active duty service or secondary to his service-connected right radical nephrectomy under 38 C.F.R. § 3.310. This matter was previously before the Board in May 2018, where it was remanded for a VA examination and accompanying medical nexus statements. The Veteran attended a VA examination in July 2020 to assess the nature and severity of his claimed internal bleeding. The VA examiner confirmed the diagnosis of internal bleeding, and the Veteran’s VA treatment records document episodes of melena suggestive of gastric bleeding. The VA examiner charted that the Veteran experienced internal bleeding in 2000. Regarding direct service connection, the VA examiner noted that the Veteran’s service treatment records were negative for the presence of internal bleeding, and this condition did not arise until decades after separation from service. The VA examiner stated that the Veteran’s internal bleeding was less likely than not caused by his service-connected right radical nephrectomy, noting that the Veteran’s gastric bleeding was caused by the Veteran’s gastric bypass surgery and unrelated to the kidneys. The July 2020 VA examiner has positively linked the Veteran’s internal bleeding to his gastric bypass surgery. The record establishes that the Veteran underwent gastric bypass in an attempt to overcome his morbid obesity. As noted above, the evidence is in relative equipoise regarding the etiology of the Veteran’s obesity, and it has been sufficiently established that his obesity was caused or aggravated by his service-connected left knee disability. The causal chain discussed in the General Counsel’s opinion regarding obesity as an intermediary has been established, and through this chain, probative medical evidence has linked the Veteran’s internal bleeding to his gastric bypass surgery, which was performed to overcome obesity caused or aggravated by his service-connected left knee disability. In light of the above analysis, the requisite elements for service connection have been established and the Veteran’s appeal seeking entitlement to service connection for internal bleeding have been met. Given the Board’s grant of this claim on a separate factual basis, there is no need to evaluate the matter further under the Veteran’s claims of direct service connection or his claims that this disability is secondary to his service-connected right radical nephrectomy. Entitlement to service connection for anemia is granted. The Veteran seeks entitlement to service connection for anemia, claimed as originally developed during his active duty service or secondary to his service-connected right radical nephrectomy under 38 C.F.R. § 3.310. This matter was previously before the Board in May 2018, where it was remanded for a VA examination and accompanying medical nexus statements. The Veteran attended a VA examination in July 2020 to assess the nature and severity of his claimed anemia. The VA examiner charted that the Veteran experienced iron deficiency anemia in 2000. The Veteran’s VA treatment records similarly confirm a diagnosis of anemia during the appellate period. Regarding direct service connection, the VA examiner noted that the Veteran’s service treatment records were negative for the presence of anemia, and this condition did not arise until decades after separation from service. The VA examiner stated that the Veteran’s anemia was less likely than not caused by his service-connected right radical nephrectomy because the Veteran’s anemia was caused by his gastric bleeding. The Board has granted entitlement to service connection for the Veteran’s internal bleeding, supra. As the July 2020 VA examiner has competently determined that the Veteran’s anemia was caused by his now service-connected internal bleeding, the requisite elements of secondary service connection under 38 C.F.R. § 3.310 have been satisfied. The Veteran’s appeal seeking entitlement to service connection for anemia is granted. Given this award of benefits, which constitutes a full grant of the benefits sought on appeal, there is no need to analyze this claim under any additional theories of entitlement raised by the Veteran or the evidence of record. Cynthia M. Bruce Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Galante 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.