Citation Nr: 21021460 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 10-24 321 DATE: April 13, 2021 ORDER Service connection for fecal incontinence, as secondary to service-connected diabetes mellitus or low back disabilities, is denied. REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. FINDING OF FACT The Veteran’s fecal incontinence is not secondary to his service-connected diabetes mellitus or low back disabilities. CONCLUSION OF LAW The criteria for service connection for fecal incontinence, as secondary to service-connected diabetes mellitus or low back disabilities, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Army from August 1968 to August 1971. These matters come before the Board of Veterans’ Appeals (Board) on appeal from the February 2009 and March 2010 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded these issues in June 2018 for further development, which has since been completed with respect to the issue of fecal incontinence. The issues of entitlement to service connection for hypertension and acquired psychiatric disorder are discussed in the remand section below. The Board also remanded a claim for service connection for chest pain. In a November 2020 rating decision, the RO granted service connection for coronary artery disease, which included the claimed condition for chest pain. As this constitutes a full award of the benefit sought on appeal, this issue is no longer before the Board. 1. Entitlement to service connection for fecal incontinence, as secondary to service-connected diabetes mellitus or low back disabilities. The Veteran contends his fecal incontinence is secondary to his service-connected diabetes mellitus and low back disabilities. See, e.g., April 2004 VA examination report; see also, April 2009 VA Form 21-4138, Statement in Support of Claim. Secondary service connection may be granted for a disability that is proximately due to or the result of a service-connected disability and includes the concept of aggravation of a nonservice-connected disability by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). Consistent with the Veteran’s contention, the record does not show onset in service or a causal nexus to service. Thus, the Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). The Veteran has a current diagnosis of fecal incontinence. See July 2009 VA examination report. The question for the Board is whether the Veteran’s fecal incontinence disability is either proximately due to, or aggravated beyond its natural progress by, his service-connected diabetes mellitus and low back disabilities. Based on the evidence, the Board concludes that the preponderance of the evidence weighs against finding that the Veteran’s fecal incontinence disability is secondary to his service-connected diabetes mellitus and low back disabilities. Historically, the Veteran had a general VA examination in October 1971. The genitourinary system was found to be normal. At a February 2004 VA spine examination, the Veteran denied fecal incontinence, even though he complained of cramps and numbness of both lower extremities. At his April 2004 VA genitourinary examination, the Veteran denied incontinence and use of absorbent material. The December 2006 and June 2008 VA spine examination reports reflected no fecal incontinence history was reported. The Veteran underwent a VA examination in July 2009. The examination report indicated that he had a diagnosis of fecal incontinence. The examiner opined that this disability is not related to or secondary to his service-connected diabetes mellitus because there was “normal anal sphincter tone,” but did not address aggravation. In January 2012, the Veteran had a general VA examination in connection with his claim for a total disability rating based on individual unemployability due to service-connected disability, but the report did not address an incontinence disability. Pursuant to the June 2018 Board remand, a VA medical opinion was obtained in October 2020. The examiner opined that the Veteran’s fecal incontinence was not aggravated by a service-connected disability. The rationale was that there was normal sphincter tone found at the July 2009 VA examination. After reviewing the claims file and VA electronic medical records, the examiner found them to be silent for fecal incontinence. The examiner found there was no aggravation because the claims file and VA electronic records were silent for aggravation as in surgery, emergency visits, hospitalization or follow up for fecal incontinence. The Veteran’s VA and private treatment records do not show a patient medical history for or reports of fecal incontinence. Based on the foregoing, service connection is not warranted on a secondary basis. The probative evidence of record has not established that the Veteran’s fecal incontinence was proximately caused by or aggravated by his service-connected diabetes mellitus or low back disabilities. The Board finds the consideration of both the July 2009 VA examination report and October 2020 VA medical opinion most probative in this regard; there is no medical evidence of record indicating a link between fecal incontinence to service-connected diabetes mellitus or low back disabilities, and the evidence does not show aggravation. There is no medical evidence to the contrary. While the Board acknowledges the Veteran’s sincere belief that his fecal incontinence is due to service-connected diabetes mellitus, he is not competent to provide an etiology opinion, as the specific issue in this case fall outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Nothing in the record demonstrates the Veteran received any special training or acquired any medical expertise to be considered competent to provide a nexus opinion in this case. Accordingly, his reported statement does not constitute competent medical evidence and lacks probative value. In sum, the competent and persuasive evidence is against finding for service connection for fecal incontinence, as secondary to service-connected diabetes mellitus or low back disabilities. There is no doubt to be resolved; service connection is not warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 2. Entitlement to service connection for hypertension is remanded. The Veteran asserts his hypertension is secondary to his service-connected diabetes mellitus. At a VA examination in July 2009 an examiner opined that his hypertension is not related to, or secondary to, his service-connected diabetes mellitus type II because no microalbuminuria was present. The Board remanded this matter in June 2018 to obtain a for a supplemental medical opinion for two reasons: 1) to obtain an opinion regarding the aggravation prong of secondary service connection and 2) to obtain a supplemental opinion explaining the significance of the absence of microalbuminuria referenced by the July 2009 examiner A VA medical opinion was obtained in October 2020. The examiner considered aggravation as directed, but did not address the significance of microalbuminuria noted in the July 2009 VA examination report because the Board inadvertently omitted this instruction from the June 2018 remand directives. While the Board sincerely regrets the additional delay, an addendum opinion is necessary. 3. Entitlement to service connection for an acquired psychiatric disorder is remanded. Unfortunately, there has not been substantial compliance with the Board’s June 2018 remand directives regarding this matter and another remand is required. See Stegall, 11 Vet. App. at 271. In the June 2018 remand, the Board explained that the record contained multiple diagnoses of psychiatric disorders namely, generalized anxiety disorder, neurotic depression, and unspecified depression. However, the August 2008 VA examiner did not consider whether all the Veteran’s psychiatric disorders were aggravated by his service-connected disabilities. On remand, the November 2020 VA examiner only discussed the Veteran’s generalized anxiety disorder, but did not provide an opinion addressing his neurotic and unspecified depression diagnoses. In addition, the examiner only discussed the anxiety disorder in connection with the Veteran’s service-connected mild cognitive impairment, but not with respect to the other service-connected disabilities. Accordingly, a remand is required for an addendum opinion. See Stegall v. West, 11 Vet. App. 268, 271 (1998). As noted by the June 2018 Board remand, the record contains adequate evidence relating to the direct theory of entitlement, so no additional development is needed in that regard. The matters are REMANDED for the following actions: 1. Return the file to the October 2020 VA examiner for an addendum opinion on the hypertension claim. If that examiner is unavailable, the opinion should be provided by an appropriate clinician who must review the claims file. The examiner is asked to provide a supplemental opinion and rationale explaining the significance of the absence of microalbuminuria (referenced by the July 2009 VA examiner) as it pertains to whether the Veteran’s hypertension is proximately caused or aggravated by his service-connected diabetes mellitus. 2. Return the file to the November 2020 VA examiner for an addendum opinion on the psychiatric disorders. If that examiner is unavailable, the opinion should be provided by an appropriate clinician who must review the claims file. The examiner is to provide an opinion as to whether it is at least as likely as not that any of the Veteran’s current psychiatric diagnoses (which include anxiety disorder, neurotic depression, and unspecified depression) are either proximately caused by OR aggravated by any of his service-connected disabilities (i.e., diabetes mellitus, low back pain, polyradiculopathy, and erectile dysfunction). Opinions and rationales for both proximate causation and aggravation must be provided. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Tang, 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.