Citation Nr: 21021037 Decision Date: 04/09/21 Archive Date: 04/09/21 DOCKET NO. 11-00 217A DATE: April 9, 2021 ORDER 1. Entitlement to service connection for coronary artery disease (CAD) as secondary to cervical and/or lumbar spine disabilities, is denied. 2. Entitlement to service connection for diabetes mellitus type II (DMII) as secondary to cervical and/or lumbar spine disabilities, is denied. 3. Entitlement to service connection for hypertension (HTN) as secondary to cervical and/or lumbar spine disabilities, is denied. FINDINGS OF FACT 1. CAD is not caused or aggravated by service-connected cervical and/or lumbar spine disabilities. 2. DMII is not caused or aggravated by service-connected cervical and/or lumbar spine disabilities. 3. HTN is not caused or aggravated by service-connected cervical and/or lumbar spine disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for CAD as secondary to cervical and/or lumbar spine disabilities have not been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). 2. The criteria for service connection for DMII as secondary to cervical and/or lumbar spine disabilities have not been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). 3. The criteria for service connection for HTN as secondary to cervical and/or lumbar spine disabilities have not been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from October 1971 to October 1974. The Veteran died in January 2017, and the appellant is his surviving spouse. These matters were previously denied by the Board in July 2019, after which the Veteran appealed the matters to the United States Court of Appeals for Veterans Claims (Court). In February 2020, the Secretary of Veterans Affairs (VA) and the Veteran (parties) agreed to a Joint Motion for Partial Remand (JMPR) and the Court granted the parties’ motion later that same month. Additionally, these matters were most recently remanded by the Board in October 2020 for additional development, specifically in order to obtain an expert medical opinion. The record reflects that VA obtained the requested opinion in October 2020 and December 2020, and therefore, the Board finds that there has been substantial compliance with prior remand directives, such that adjudication of the appeal may proceed. The Board is also mindful that the appellant, through her attorney, previously submitted a VA Form 10182 in May 2019, following the issuance of an April 2019 supplemental statement of the case (SSOC) addressing the issues on appeal. Generally, this action would opt the appeal into the Appeals Modernization Act (AMA); however, given the subsequent procedural history within the legacy system, including the July 2019 Board denial, February 2020 JMPR, and October 2020 Board remand where there was no indication that the appellant wanted to opt into the AMA, the Board finds that there is no harm to the appellant for these matters to remain in the legacy system. Service Connection 1. Entitlement to service connection for CAD (CAD), to include as secondary to cervical and/or lumbar spine disabilities. 2. Entitlement to service connection for DMII (DMII), to include as secondary to cervical and/or lumbar spine disabilities. 3. Entitlement to service connection for HTN (HTN), to include as secondary to cervical and/or lumbar spine disabilities. The Veteran, and now the appellant, have asserted that the Veteran’s CAD, DMII, and HTN were caused by weight gain resulting from service-connected neck and back injuries due to a fall during his participation in a VA compensated work therapy (CWT) program, which ultimately rendered him sedentary and unable to move. The Board is mindful that VA has previously awarded service connection for intervertebral disc syndrome with degenerative arthritis and a neck injury from August 15, 2007. Additionally, prior to his death in January 2017, the Veteran was diagnosed with CAD, DMII, and HTN. Thus, the relevant inquiry in these matters is whether the Veteran’s CAD, DMII, and HTN are secondary to his service-connected intervertebral disc syndrome with degenerative arthritis and/or neck injury. As noted above, these matters were remanded by the Board in October 2020 following a February 2020 JMPR, wherein the parties agreed that the appellant’s claims as to CAD, DMII, and HTN were inextricably intertwined with the issue of entitlement to compensation under 38 U.S.C. § 1151 for a neck disability (this claim for a neck disability was subsequently granted by VA and is no longer before the Board on appeal). In the JMPR, the parties noted that the appellant had asserted that the Veteran’s CAD, DMII, and HTN were caused by weight gain resulting from neck and back injuries due to a fall that rendered him unable to move. Specifically, the parties agreed that the Board’s July 2019 decision failed to reconcile a March 2019 VA examiner’s opinion that the low back and neck injuries did not curtail all exercises and therefore lead to weight gain with other evidence of record, including favorable VA opinions, suggesting that the Veteran’s injuries curtailed his ability to move. In this regard, the Board notes that the February 2020 JMPR cited to a November 2014 VA thoracolumbar spine examination report that documents that the Veteran reported that his low back pain limited his physical activity and that he was mostly confined to a motorized wheelchair. The examiner also noted that the Veteran had multiple comorbidities including PTSD, DM, CAD, morbid obesity, significant psychosocial problems, and fibromatosis of the feet. As to the feet, the examiner documented that such disability prevented the Veteran from walking. Further, the VA examiner documented that the Veteran’s lumbar spine disability resulted in significant functional impairment of mobility in that the Veteran reported he was confined to a wheelchair. Additionally, the parties within the February 2020 JMPR noted that the Board’s July 2019 decision found that special monthly compensation (SMC) for aid and attendance was warranted, at least in part, due to the Veteran’s ambulatory difficulties. As such, the parties agreed that the Board should address the discrepancy between the evidence regarding the Veteran’s ambulatory abilities following his injuries and then discuss whether a new medical opinion is warranted. Following the February 2020 JMPR, the Board remanded these matters in October 2020 for a medical opinion concerning the above claims. Following a review of the evidence of record, including as discussed further herein, the Board finds that the preponderance of evidence weighs against the appellant’s claims for secondary service connection. The reasons for this decision follow. In March 2019, a VA examiner reviewed the evidence of record and opined that the Veteran’s conditions were not secondary to his service-connected disabilities, specifically to include his low back disability. First, regarding the Veteran’s CAD, the VA examiner stated that coronary artery bypass graft (CABG) due to CAD is most commonly caused by atherosclerosis, and that contribution to the development of atherosclerotic changes in the coronary arteries are multifactorial, with causes include: endothelial dysfunction, inflammation, and plaque deposition with subsequent rupture. Additionally, the examiner noted that some, but not all, risk factors for development of CAD include age, genetic factors, HTN, diabetes, dyslipidemia, and smoking. Second, regarding the Veteran’s HTN, the VA examiner stated that HTN is related to pathology in the peripheral arteries, which are the blood supply to the body, head, and limbs, and that HTN is a result of pathologic changes in the heart stroke volume and the arterial resistance of the body’s vascular system. The examiner stated that known risk factors for HTN include disorders that increase sympathetic neural activity with enhancing beta-adrenergic responsiveness, or increase angiotensin II activity and mineral corticoid excess. Third, regarding the Veteran’s DMII, the VA examiner stated that DMII is a pathologic condition due to impaired glucose secretion and metabolism. The examiner noted that one significant risk factor for development of diabetes mellitus is obesity due to excessive caloric intake and a sedentary lifestyle. The examiner acknowledged that weight gain and diet can be a risk factor for CAD, HTN, and DMII as well, but stated that weight gain is not a forgone consequence of low back pathology. Significantly, the examiner stated that weight gain is purely a function of caloric intake exceeding caloric expenditure, and while low back pathology may curtail certain exercises, it does not necessarily curtail all exercises. Furthermore, the examiner noted that low back pathology does not impact dietary modifications at all. As such, the examiner concluded that any possible decrease in the Veteran’s caloric expenditure due to back pain could have been compensated for by following a proper diet in order to prevent weight gain. Therefore, the examiner opined that it is less likely as not that the Veteran’s CAD, HTN, and DMII were proximately due to, the result of, or aggravated by the Veteran’s service-connected disabilities, specifically to include his low back disability. As noted above, the parties agreed in the February 2020 JMPR that the Board previously failed to reconcile March 2019 VA examiner’s opinion that the Veteran’s low back and neck injuries did not curtail all exercises and therefore lead to weight gain with other evidence of record, including favorable VA opinions, suggesting that the Veteran’s injuries curtailed his ability to move. In this regard, the Board notes that the parties within the February 2020 JMPR cited to a November 2014 VA thoracolumbar spine examination report that documents that the Veteran reported that his low back pain limited his physical activity and that he was mostly confined to a motorized wheelchair. The examiner also noted that the Veteran had multiple comorbidities including PTSD, DM, CAD, morbid obesity, significant psychosocial problems, and fibromatosis of the feet (which prevents him from walking). Further, the VA examiner documented that the Veteran’s lumbar spine disability resulted in significant functional impairment of mobility in that the Veteran reported he was confined to a wheelchair. The Board has carefully reviewed the November 2014 VA examination report regarding the Veteran’s service-connected back disability. Therein, the Veteran reported that his activities were limited to a few steps due to back pain, and that he was mostly confined to a motorized wheelchair. He reported that he had sustained at least three falls in the previous 12 months. The examiner noted that the Veteran had multiple comorbidities, including nonservice-connected PTSD, morbid obesity, fibromatosis of the feet, and significant psychosocial problems, as well as service-connected DMII and CAD. The examiner further stated that the Veteran was seeing podiatry for treatment of his plantar fibromatosis, which prevented the Veteran from walking. A physical examination showed that the Veteran’s physical activities were limited to a few steps, and that he was mostly confined to a wheelchair. The Veteran reported constant use of a wheelchair and occasional use of a walker for ambulation due to back and foot pain. The VA examiner noted functional impact upon the Veteran’s ability to work in that his mobility was significantly impaired due to reported wheelchair confinement. Notably, the Board finds that the November 2014 VA examiner’s notations of functional impairment and limitation to a wheelchair appear to be based largely upon the Veteran’s lay reports. Moreover, the VA examiner acknowledged that the resulting functional impairment was due to service-connected back pain, as well as nonservice-connected foot pain. Significantly, the examiner documented the Veteran’s report that his nonservice-connected plantar fibromatosis prevented him from walking. The notation did not include that the lumbar spine disability prevented the Veteran from walking. In any event, the inconsistent findings of the March 2019 VA examiner that the Veteran’s conditions did not necessarily curtail all exercise and the November 2014 VA examiner’s finding of significant functional impairment of mobility based upon the Veteran’s reports that he was confined to a wheelchair bear on the Veteran’s physical limitations and the extent of his ability to exercise to curtail weigh gain. However, the March 2019 VA examiner further stated that the Veteran’s service-connected low back pathology did not impact dietary modifications at all. As such, the examiner concluded that any possible decrease in the Veteran’s caloric expenditure due to back pain could have been compensated for by following a proper diet in order to prevent weight gain. The Board finds this additional conclusion highly probative, as the examiner noted independent of whether or not the Veteran retained the ability to perform physical exercise, he could have otherwise compensated for any decrease in caloric expenditure by dietary changes, which the Board finds reasonably could be performed whether or not the Veteran was restricted to a wheelchair or retained the ability to perform physical exercise. Moreover, the additional VA expert medical opinion evidence of record further weighs against the appellant’s claims. In October 2020, a VA examiner opined that it was not at least as likely as not that the Veteran’s cervical spine disability caused his CAD, DMII, or HTN. The examiner stated that HTN was diagnosed in 2005 and predated the cervical spine condition, while both DMII and CAD are multifactorial and are largely influenced by a variety of factors including diet and genetics. The examiner stated that while a cervical spine disability can cause weight gain that can represent a risk factor for both conditions, weight gain is multifactorial and can still be prevented by dietary discretion and non-weight-bearing exercise, which are not prohibited by the cervical spine condition. The examiner also opined that it was not at least as likely as not that the Veteran’s cervical spine disability aggravated his CAD, DMII, or HTN. The examiner stated that the most recent blood pressure records demonstrate blood pressure readings in the 140s/60s on a single antihypertensive medication, which falls within the projected natural history of the condition and does not represent aggravation (beyond natural progression). Additionally, the examiner stated that neither DMII or CAD were diagnosed until well after the Veteran’s neck condition (2014) and therefore, could not have been aggravated by the neck condition given that they were not pre-existing. In December 2020, the same VA examiner opined that it was not at least as likely as not that the Veteran’s lumbar spine disability caused his CAD, DMII, or HTN. The examiner stated that disorders of the lumbar spine are not an established etiology of CAD or DMII in the medical literature, and while a lumbar spine disability can cause weight gain that can represent a risk factor for CAD, DMII, and HTN, weight gain is multifactorial and can still be prevented by dietary discretion and non-weight bearing exercise which are not prohibited by the lumbar spine condition. Furthermore, the examiner stated that CAD, DMII, and HTN are multifactorial and are largely influenced by a variety of factors including diet and genetics. Similarly, the examiner opined that it was not at least as likely as not that the Veteran’s lumbar spine disability aggravated his CAD, DMII, or HTN. Regarding CAD, the examiner noted that the Veteran underwent a successful coronary artery bypass graft surgery in 2014 and was without significant residual deficit or functional limitation from CAD, which falls within the projected natural history of the condition and does not represent aggravation (beyond natural progression). Regarding DMII, the examiner stated that the Veteran’s DMII was controlled without insulin and had not resulted in prior hospitalization, which falls within the projected natural history of the condition and does not represent aggravation (beyond natural progression). Finally, regarding HTN, the examiner noted that the most recent blood pressure records demonstrate blood pressure readings in the 140s/60s on a single antihypertensive medication, which falls within the projected natural history of the condition and does not represent aggravation (beyond natural progression). For similar reasons as previously discussed concerning the March 2019 VA opinion, the Board finds that the October 2020 and December 2020 VA opinions weigh against the appellant’s claims. As above, regardless of the conflicting evidence of record concerning whether the Veteran retained the physical ability to exercise in order to curtail weight gain, the October 2020 and December 2020 VA opinions further noted that dietary discretion and non-weight bearing exercise were not prohibited by the Veteran’s service-connected cervical spine and lumbar spine disabilities. As such, the Board finds it highly probative that despite the focus of the February 2020 JMPR on the extent of the Veteran’s physical impairment, the probative medical opinion evidence of regard nevertheless weighs in favor of a finding that the Veteran was not prohibited from compensating for any decrease in caloric expenditure by dietary discretion and changes, and non-weight-bearing exercises, independent of his physical impairment. Additionally, to the extent that the parties within the February 2020 JMPR also noted that the Board’s July 2019 decision found that SMC was warranted for aid and attendance due, at least in part, to the Veteran’s ambulatory difficulties, the Board finds it significant that the evidence of record is inconsistent as to the extent of the Veteran’s physical impairment, as well as whether or not such impairment was due to service-connected lumbar or cervical spine disabilities. Notably, a January 2015 VA examination report regarding aid and attendance found that the Veteran had functional impairment due to both service-connected and nonservice-connected disabilities. Notably, the majority of the impairments listed by the VA examiner appear to involve the Veteran’s nonservice-connected foot condition, which resulted in an inability to stand for prolonged periods of time, unsteady gait, poor balance, increased risk for falls, limited ambulation for short distances, poor strength and endurance in the bilateral lower extremities, and required aids for ambulation. This documented finding is consistent with what the Veteran reported to what was documented in the November 2014 VA examination report. This evidence does not weigh in favor of a finding that the Veteran’s service-connected lumbar spine condition was the cause of his physical and functional impairment. The Board has also considered the appellant’s March 2015 statement that the Veteran became more sedentary and gained about 100 pounds, which led to his current CAD, HTN, and DMII. While the appellant asserted that the Veteran required daily help to bathe, dress, clean, transport, and fix meals, the Board finds that such reports are inconsistent with the additional objective evidence of record, and, as such, the uncorroborated lay reports are of limited probative value. Significantly, VA treatment records from the following month, in April 2015, document that a “Katz Index” evaluation of the Veteran’s independence in activities of daily living (ADLs) found that the Veteran received or required no assistance with activities including bathing, dressing, toileting, transferring, continence, and feeding. His resulting score was 18/18, which is a high index that indicates independence, while a lower index means dependence on others to help with ADLs. Similarly, a concurrent “Lawton-Brody Instrumental Activities of Daily Living (IADL) Scale” evaluated the Veteran’s abilities to use a telephone, shop, prepare food, clean house, do laundry, travel, maintain medication, and handle finances. The Veteran’s resulting score was 8/8, which is a high score that indicates independent living, while a lower score indicates dependence on others to help with daily activities. In sum, there were no concerns for the Veteran’s ADLs or IADLs. Similarly, a subsequent September 2015 VA treatment record shows that the examiner documented that after his coronary bypass surgery, the Veteran could bathe and feed himself, and he was also able to attend VA treatment without major issues. It was noted that he needed a scooter to get around, but he was able to follow the daily program without physical issues. This is further evidence that the Veteran was not experiencing a high degree of physical or functional impairment due to his service-connected lumbar spine and/or cervical spine disabilities. To the extent that a prior August 2015 VA treatment record documents that the Veteran needed assistance with ADLs including bathing, dressing, feeding, bathing, toileting, and ambulating, the Board finds probative that these findings were rendered in the context of a psychiatric follow-up visit. Notably, the Veteran was not service connected for a psychiatric disability, including PTSD, as he previously claimed. As such, this does not weigh in favor of the appellant’s current claims. In sum, the Board concludes that despite the inconsistent findings discussed within the February 2020 JMPR, the preponderance of the evidence of record is against a finding that the Veteran’s service-connected lumbar and/or cervical spine disabilities resulted in physical limitations that caused him to become sedentary and gain weight, thereby resulting in, causing, or aggravating his CAD, DMII, or HTN. As discussed above, the Board affords the most probative value to the objective evidence of record which documents that the Veteran retained the ability to perform ADLs and IADLs to the extent that the Veteran was not incapacitated. The limited findings of significant functional and physical impairment appear to be based largely upon uncorroborated lay reports, and therefore, are of lessened probative value. Moreover, and more importantly, as discussed above, independent of whether or not the Veteran experienced significant physical or functional limitation upon his ability to exercise in order to avoid a sedentary lifestyle and weight gain, the Board places high probative value upon the VA opinions above that note that regardless of physical limitations, the Veteran would not have been precluded from undertaking dietary changes or restrictions, as well as non-weight-bearing exercise, in order to counter any drop in caloric expenditure. Non-weight-bearing exercise would include using a stationary bicycle. While the Veteran complained that his feet prevented him from walking, which could impact his ability to use a stationary bicycle, that is a non-service-connected disability. Additionally, there is no competent evidence that the service-connected cervical spine and/or lumbar spine disabilities prevented the Veteran from changing his diet and taking in less calories to combat his weight gain. Thus, even accepting that the Veteran had been awarded aid and attendance, the preponderance of the evidence is against a finding that he was unable to perform non-weight-bearing exercise and/or reduce his caloric intake. For all these reasons, the Board finds the preponderance of evidence weighs against the appellant’s claims for service connection for CAD, DMII, and HTN, as being secondary to cervical and/or lumbar spine disabilities, and the claims are denied. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Chad Johnson, 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.