Citation Nr: 21016187 Decision Date: 03/22/21 Archive Date: 03/22/21 DOCKET NO. 17-58 111 DATE: March 22, 2021 ORDER Entitlement to service connection for cerebrovascular disease, to include a stroke and a front dural mass, caused by service-connected ischemic heart disease, is granted. Entitlement to service connection for carotid artery disease, caused by service-connected ischemic heart disease, is granted. FINDINGS OF FACT 1. The evidence is in equipoise regarding whether the Veteran’s cerebrovascular disease is at least as likely as not due to or caused by service-connected disability. 2. The evidence is in equipoise regarding whether the Veteran’s carotid artery disease is at least as likely as not due to or caused by service-connected disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for cerebrovascular disease, to include a stroke and a front dural mass, caused by service-connected ischemic heart disease, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 2. The criteria for entitlement to service connection for carotid artery disease, caused by service-connected ischemic heart disease, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1961 to April 1990. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a March 2017 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In March 2019, the Board denied the claims. The Veteran appealed the March 2019 Board decision to the United States Court of Appeals for Veterans Claims. In January 2020, the Court granted the parties’ Joint Motion for Partial Remand filed by the parties, vacating the Board’s decision on the claims, and remanding the claims to the Board for action consistent with the terms of the Joint Motion. In April 2020, the Board remanded these claims to the Agency of Original Jurisdiction for additional action. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c); 38 U.S.C. § 7107(a)(2). The Veteran originally submitted separate claims of entitlement to service connection for a stroke and service connection for a frontal dural mass compatible with an old ischemic event. The Board, based on the evidence of record, has recharacterized both claims as a single claim for service connection for cerebrovascular disease, to include a stroke and a front dural mass. Clemons v. Shinseki, 23 Vet. App. 1 (2009) Service Connection Service connection may be established for disability caused by disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. In order to establish service connection for a claimed disability, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence, generally medical, of a causal relationship between the claimed in service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247 (1999). Service connection may also be established for any disease initially diagnosed after service, when the evidence establishes that the disease was incurred in-service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503 (1992). The disease entity for which service connection is sought must be chronic rather than acute and transitory in nature. For the showing of chronic disease in service, a combination of manifestations must exist sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. Secondary service connection may be established for a disability that is proximately due to, or aggravated by, a service-connected disability. 38 C.F.R. § 3.310. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). Lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and may provide sufficient support for a claim of service connection. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran is competent to provide testimony concerning factual matters of which he has firsthand knowledge, such as experiencing a physical symptom such as pain. Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). Therefore, the Board must assess the competence and credibility of lay statements. Barr v. Nicholson, 21 Vet. App. 303 (2007). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while weight and credibility are factual determinations going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67 (1997). A Veteran need only demonstrate that there is an approximate balance of positive and negative evidence to prevail. To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). While the Board must provide reasons and bases supporting a decision, there is no need to discuss, in detail, the evidence submitted by or on behalf of the Veteran. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence of record. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed. Timberlake v. Gober, 14 Vet. App. 122 (2000). 1. Entitlement to service connection for cerebrovascular disease. 2. Entitlement to service connection for carotid artery disease. The Veteran is seeking service connection for cerebrovascular disease and carotid artery disease. In both cases, the Veteran contends that the currently diagnosed disabilities are secondary to herbicide agent exposure while serving in Vietnam. In the alternative, the Veteran contends that the current disabilities are secondary to service-connected ischemic heart disease. Exposure to herbicide agents during the Veteran’s service is presumed. During VA examination in October 2020, after review of the claims file and in-person examination, the examiner, a physician, opined that carotid artery disease and cerebrovascular disease were at least as likely as not (50 percent or greater probability) incurred in or caused by service-connected ischemic heart disease (IHD). The examiner explained that vasculopathy is a known condition that refers to the involvement of multiple vascular systems throughout the body and is an indication of diffuse atherosclerosis throughout the arterial cardiovascular system. The Veteran has service-connected IHD and that disability alone is an indication that the cardiovascular system is diseased with atherosclerosis. Evidence of that can be found in the diagnosis of atherosclerosis of the carotid arteries and cerebral arteries. Atherosclerosis of the carotid arteries represents a progression of the service-connected IHD. The examiner also cited to a study published by the National Institute of Health, titled Coronary and carotid atherosclerosis: similarities and differences, which cites “the prevalence of severe carotid stenosis increases with prevalence of coronary stenosis, with the latter being found in a significant number of stroke claimants... Overall, the evidence shows that a clear relationship exists between disease in the coronary and carotid arteries, since conventional risk factors and the extent of stenosis and/or previous events emanating from one artery have a strong bearing on the prevalence of events in the other artery.” The examiner concluded by stated that carotid artery disease and cerebrovascular disease were caused by ischemic heart disease, not aggravated. The Board assigns great probative value to the October 2020 VA opinion because of the training, experience, and thoroughness of the examiner. Among the factors for assessing the probative value of a medical opinion are the physician’s access to the claims file and the thoroughness and detail of the opinion. Hayes v. Brown, 5 Vet. App. 60 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence); Wood v. Derwinski, 1 Vet. App. 190 (1992). The probative value of medical evidence is based on the physician’s knowledge and skill in analyzing the data, and the medical conclusion he reaches. As is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. Guerrieri v. Brown, 4 Vet. App. 467 (1993). The October 2020 VA opinion was made after a review of the record, was consistent with the evidence in the case, and provided adequate reasons and bases in support of the conclusion. The October 2020 VA examiner opined that the Veteran met the diagnostic criteria for carotid artery disease and cerebrovascular disease which, in the examiner’s opinion, were caused by service-connected ischemic heart disease. The opinion of the October 2020 VA examiner is highly probative because it is supported by detailed rationale and provided by a trained medical professional. The VA examiner specifically identified and discussed the Veteran’s contentions and theory concerning service and the claimed disability. Thus, the Board finds the October 2020 VA medical opinion to be competent and credible. The Board acknowledges that there may be contradictory evidence of record. However, the Board cannot ignore the medical evidence finding that carotid artery disease and cerebrovascular disease are secondary to the Veteran’s service- connected ischemic heart disease. Because of the detail and thoroughness of the October 2020 VA examination, the Board finds that the evidence is, at least, in equipoise regarding whether currently diagnosed carotid artery disease and cerebrovascular disease are secondary to service-connected ischemic heart disease. Accordingly, resolving reasonable doubt in the Veteran’s favor, the Board finds the competent medical evidence supports a finding that carotid artery disease and cerebrovascular disease are caused by service-connected ischemic heart disease. Therefore, service connection for carotid artery disease and cerebrovascular disease is warranted as those disabilities were caused by a service-connected disability. Service connection for carotid artery disease and service connection for cerebrovascular disease is granted. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. App. 49 (1990). Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mondesir, Eric 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.