Citation Nr: 21015905 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 14-28 499A DATE: March 18, 2021 ORDER Entitlement to service connection for coronary artery disease (CAD) is denied. REMANDED Entitlement to service connection for tinnitus, to include as secondary to service-connected bilateral hearing loss, is remanded. FINDING OF FACT Coronary artery disease did not have onset during service and is not otherwise related to service. CONCLUSION OF LAW The criteria for service connection for residuals of coronary artery disease have not been met. 38 U.S.C. §§ 1110, 1116 (West 2014); 38 C.F.R. §§ 3.303, 3.307(a), 3.309(e) (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1966 to February 1968.This matter is before the Board of Veterans' Appeals (Board) on appeal of an August 2013 and September 2019 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. A hearing before the undersigned Veterans Law Judge was held in September 2017. A transcript of the hearing is associated with the claims file. 1. Entitlement to service connection for CAD is denied. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2017). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2017). In addition, service connection for certain chronic diseases, such as organic heart disease, may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a) (2017); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Additionally, for certain chronic diseases with potential onset during service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309 (2017); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Initially, t Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). According to the December 2020 VA examination, the Veteran was diagnosed with acute myocardial infarction, coronary artery disease, heart valve replacement, and coronary artery bypass graft. Next, the Board finds that there was an in-service injury. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). August 1984 service treatment records (STRs) indicate that the Veteran was stationed at Camp Lejeune. Military personnel records indicate that the Veteran was still stationed at Camp Lejeune in April 1968. Thus, the Veteran was exposed to contaminated water. First, regarding the presumptions based on heart disease as a chronic disease or based on continuity of symptomatology, there is no evidence, lay or medical, that the disease began in service and continued or that it was diagnosed within the first year following his separation from service. 38 C.F.R. §§ 3.303 (b), 3.309 (2019). The Veteran's service treatment records are absent of complaints or treatment for heart disease. There is no evidence of treatment for heart disease until October 1999, when the Veteran underwent an aortic root replacement and coronary artery bypass, several decades after the Veteran left service. The Veteran does not provide lay statements of continuity. Second, regarding presumptive service connection for Camp Lejeune, the Board finds that the criteria are not met. To establish presumptive service connection for a disease associated with exposure to contaminated water at Camp Lejeune, a claimant must show the following: (1) that the Veteran served at Camp Lejeune for no less than 30 days (either consecutive or nonconsecutive) from August 1, 1953 to December 31, 1987; (2) that the veteran suffered from a disease associated with exposure to contaminants in the water supply at Camp Lejeune enumerated under 38 C.F.R. § 3.309(f); and (3) that the disease process manifested to a degree of 10 percent or more at any time after service. 38 C.F.R. §§ 3.307(a)(7), 3.309(f). Pursuant to 38 C.F.R. § 3.309(f), the following diseases are presumed to be associated with exposure to contaminants in the water supply at Camp Lejeune and will be service-connected even though there is no record of such disease during service (subject to the rebuttable presumption provisions of 38 C.F.R. § 3.307(d)): kidney cancer, liver cancer, Non-Hodgkin’s lymphoma, adult leukemia, multiple myeloma, Parkinson’s disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer. The Veteran’s claimed condition is not among the listed diseases presumed related to contaminated water exposure at Camp Lejeune, therefore, the Board will address the claim under direct service connection. Third, the issue for the Board to resolve is whether CAD is otherwise related to active duty, to include Camp Lejeune contaminated water exposure. The Veteran was provided with a VA examination in April 2019. The examiner determined that the Veteran’s heart condition was less likely than not related to his active duty service as there was no evidence of the Veteran being treated for heart disease in service. The examiner also noted that there was no evidence of environmental exposures related to overseas tours of duty in Korea or Vietnam. This examination was deemed inadequate in a July 2020 Board decision as the examiner’s rationale rested solely on the lack of service treatment records documenting the Veteran’s disability with no additional explanation and did not address the Veteran’s theory of exposure at Camp Lejeune. As such, the Board places less probative weight upon this opinion in determining nexus. The Veteran was provided with another VA examination in September 2020. The examiner opined that the Veteran’s heart condition was less likely than not related to his exposure to contaminated water at Camp Lejeune. The examiner noted that the Veteran’s CAD was not one of the fourteen conditions identified as having suggestive evidence of an association with TCE, PCE, or a solvent mixture exposure as identified by the National Academy of Sciences in its report on the contaminated water supply at Camp Lejeune. The examiner noted that there was no evidence or continuity of symptomatology to indicate a nexus. The examiner stated that the causes of CAD included smoking, high blood pressure, high cholesterol, diabetes, and/or a sedentary lifestyle. Risk factors of CAD included age, male sex, family history, smoking, high blood pressure, high blood cholesterol, diabetes, obesity, high stress, and/or an unhealthy diet. The examiner noted that the Veteran had risk factors associated with CAD that included a history of smoking, high blood pressure, high cholesterol, sedentary lifestyle, his age, male sex, high blood pressure, high cholesterol, obesity and an unhealthy diet. The examiner opined that the Veteran’s numerous risk factors were a more likely cause of his CAD than contamination at Camp Lejeune. The examiner then listed extensive medical literature to support his opinion. A December 2020 addendum was provided in which the examiner further explained his opinion that smoking was more likely the cause of the Veteran’s heart condition. The examiner stated that the etiology of CAD is the buildup of plaque in the arteries which is caused by smoking. The examiner noted that the Veteran smoked for 33 years and that he quit smoking after his cardiac incidents at the recommendation of his physician. The Board finds these opinions highly probative evidence as they are provided upon review of the relevant facts (to include lay statements of symptomatology that the Board found probative) and supported by explanation. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in determining probative value of a medical opinion is whether the examiner was informed of the relevant facts); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion must be supported by an analysis that the Board can consider and weigh against contrary opinions). Thus, the Board finds that the preponderance of the evidence is against finding that the Veteran’s heart condition is related to his exposure to contaminated water at Camp Lejeune. Accordingly, service connection is denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for tinnitus is remanded. Though the Board regrets the additional delay, remand is required for an adequate VA opinion. Where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The resolution of a disability during the period on appeal does not bar a grant of benefits. McLain v. Nicholson, 21 Vet. App. 319 (2007). In a November 2020 examination, the examiner found that the Veteran did not report recurrent tinnitus. Accordingly, no nexus opinion or rationale was provided. This examination is inadequate, however, as there were diagnoses during the appeal period that the examiner did not address. In an April 2010 medical treatment record the Veteran complained of intermittent tinnitus. In an April 2012 statement the Veteran stated that he had ringing in his ears that improved with the use of hearing aids. A November 2012 treatment record noted a positive history for tinnitus. In a June 2013 VA examination, the Veteran was diagnosed with recurrent tinnitus. As such, remand is required for a proper addendum opinion. The matters are REMANDED for the following action: Provide the Veteran with an appropriate examination to determine the etiology of tinnitus. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail. An explanation for all opinions expressed must be provided. The examiner must provide a proper opinion and rationale as tinnitus has been reported and diagnosed within the appellate period. First, the examiner must determine if the Veteran’s tinnitus has resolved. Second, if the tinnitus is resolved, the examiner must provide opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s previous tinnitus had its onset in service, within one year of service discharge, or is otherwise the result of a disease or injury in service. Third, if tinnitus is present, the examiner must provide opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s previous tinnitus had its onset in service, within one year of service discharge, or is otherwise the result of a disease or injury in service. Fourth, the examiner is also asked to opine on whether it is at least as likely as not (50 percent probability or more) that the Veteran's tinnitus was caused or aggravated by his service-connected bilateral hearing loss? K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board AK 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.