Citation Nr: 21023006 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 13-30 288 DATE: April 19, 2021 ORDER Entitlement to service connection for bilateral peripheral artery disease (PAD) is denied. REMANDED Entitlement to service connection for a stomach disability, to include gastroesophageal reflux disease (GERD), gastritis, and hiatal hernia, to include as secondary to service-connected ankylostomiasis (hookworm) is remanded. FINDING OF FACT The preponderance of the evidence is against finding that PAD began during active service or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for PAD have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Army from January 1952 to December 1953. The Veteran’s awards and decorations include the Purple Heart and the Combat Infantry Badge. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2011 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, denied service connection for PAD and GERD, gastritis, and hiatal hernia. The Veteran’s timely Notice of Disagreement (NOD) was received by VA in May 2011. In September 2013, the RO issued a Statement of the Case (SOC). In September 2013, the Veteran perfected a timely appeal via his submission of a VA Form 9. The Veteran was scheduled for an April 2016 Travel Board hearing at the local RO in San Juan, Puerto Rico. The Veteran cancelled his hearing before the Board. Therefore, the hearing request is deemed withdrawn. In May 2018, the Board remanded the matter for further evidentiary development. A supplemental statement of the case (SSOC) was issued in December 2020. The matter has been returned to the Board for further appellate proceedings. Entitlement to service connection for PAD is denied. The Veteran contends that his current PAD disability is related to service. See February 2017 VA examination. Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. In general, 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. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Certain chronic diseases, to include cardiovascular-renal disease, will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant.  38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In all cases, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a “competent” source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff’d, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the “authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence”). A June 1953 in-service medical note shows the Veteran received a routine chest exam and the exam found no evidence of pathology in either lung, and that a cardiovascular shadow was anatomical. A July 1953 in-service medical note states “The cardiovascular system- blood pressure 105/20 the heart is not enlarged, the heart tones are of good quality and no gross murmurs were heard…the remainder of the examination was essentially negative.” Another July 1953 in-service medical note listed the heart and lungs as normal. Also, in July 1953 the Veteran had a chest x-ray which found “There is some scarring in both upper lung fields. No definite evidence of active pulmonary disease. The heart and mediastinum are within normal limits.” The Veteran’s in-service treatment records show an electrocardiographic report from August 1953 which notes the borderline record with non-specific S-T and T wave changes, possible left ventricular hypertrophy. In the December 1953 separation medical examination, the Veteran’s lungs and chest, heart, and vascular system were all recorded as normal. A November 1993 VA medical note reports the Veteran was having dizzy spell problems. A March 1994 VA medical note reports the Veteran was experiencing blurring of vision. An August 1996 VA medical note indicates the Veteran does not have a history of PAD. A December 1997 VA medical note shows the Veteran was experiencing low blood pressure and dizziness at middle of the morning, and he was occasionally experiencing relief of the dizziness after eating food. A February 2004 VA medical note is negative for any cardiovascular complaints. An August 2006 VA medical note indicates the Veteran is experiencing cramps in his calves, especially at night. A January 2010 VA medical note indicates peripheral vascular diagnosis suspected as per physical exam, and with complaints of erectile disfunction. The VA examiner noted the Veteran’s foot exam showed abnormal deformity, specifically nail discoloration and hypertrophic nails. The exam of the pulses of the Veteran’s feet also were abnormal, with dorsalis pedis present and tibialis post decreased in both feet. The Veteran’s bilateral foot sensation was normal. The VA examiner also noted diminished circulation as evidence by absent or weakly palpable pulses and/or mild foot deformity and minor foot infection. In June 2010 the Veteran was afforded a VA examination. The VA examiner noted that the Veteran reported having an abnormal blood pressure reading of 105/20 during his military career. The Veteran also reported a history of abnormal blood pressure readings at a VA Center. He also reported he started having numbness sensation, tingling, and pain in both lower extremities since 2002. The Veteran was diagnosed with peripheral arteries disease. The VA examiner opined that the Veteran’s circulatory condition is not caused by or a result of hypertension because peripheral artery disease and hypertension are two different conditions with different etiology. The VA examiner went on to explain peripheral artery disease is caused by atherosclerosis (fatty deposits or plaques) that build up in the artery wall and reduce blood flow. A February 2011 VA medical note indicates the Veteran reported his neuropathy is worse during the nighttime. The VA examiner noted during the exam the Veteran had bilateral abnormal feet due to deformity. Additionally, the Veteran’s feet sensation exam was also abnormal and both feet had a decrease in monofilament. A November 2014 VA medical noted the Veteran’s cardiovascular system was negative for any issues. In February 2017 the Veteran was afforded another VA examination in accordance with previous remand instructions. The VA examiner confirmed the Veteran’s earlier diagnosis of peripheral vascular disease. The Veteran reported he has been suffering from leg cramps upon ambulation for the past fifteen years, and he denied history of circulatory problems while in service. The VA examiner opined the Veteran’s peripheral artery disease is less likely as not caused by or a result of active military service as there is no evidence on service treatment records. In October 2017 a VA addendum opinion was obtained in accordance with previous remand instructions. The VA examiner opined the Veteran’s claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The arterial duplex 4/2015 impression showed mild bilateral runoff disease, atherosclerosis, no hemodynamically significant stenoses or arterial occlusion. The VA examiner opined that is no evidence of significant “periphero artery disease” [sic] on today examination for patient’s age. In December 2020 a VA addendum opinion was obtained in accordance with previous remand instructions. The VA examiner opined the condition claimed was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The VA examiner explained the Veteran’s peripheroartery disease was diagnosed in 2015 approximately fifty years after discharge from service with makes the condition less likely as not related to active military service. The VA examiner went on to explain PAD is caused by atherosclerosis which is a slow and progressive circulatory disorder. Applying the facts in this case to the legal criteria set forth above, the Board concludes the preponderance of evidence is against the award of service connection for PAD. With respect to the first element necessary to establish service connection, a current disability, the Board notes the Veteran has a current disability of PAD. See December 2020 VA examination. With respect to the second element necessary to establish service connection, in-service incurrence of a disease or injury, the Veteran’s service treatment records show an August 1953 note which reported the borderline record with non-specific S-T and T wave changes, possible left ventricular hypertrophy. These records do not reflect a diagnosis of PAD. The VA examiners who have reviewed these records were in agreement that there was no indication of PAD while in service. With respect to the third element, a nexus, there is a lack of medical evidence linking the Veteran’s current PAD disability to his active service. The December 2020 VA examination notes that the Veteran was diagnosed with PAD after his discharge from service. Additionally, as mentioned above the VA examiner opined PAD is caused by atherosclerosis, which is a slow and progressive circulatory disorder. This medical opinion is consistent with the evidence of record which are negative for any symptoms or diagnosis related to atherosclerosis. Additionally, the other in-service medical notes which examined the Veteran’s heart indicate the Veteran’s heart was normal while in-service and at separation. Therefore, the VA examiner’s opinion was based on a review of the Veteran’s entire claims file and provides a well-reasoned rationale, therefore the Board assigned the December 2020 VA examination great probative weight; thus, the Board finds, the third element of service connection, nexus, has not been met. The Board has considered the Veteran’s lay assertions that his current PAD disability began in service. While the Veteran is competent to describe his in-service symptoms that he has personally experienced, there is no evidence of record which indicates that he is competent, whether by training or experience, to provide an etiological opinion with regards to his current PAD disability. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds the issue is medically complex, and that it requires interpretation of diagnostic testing to render an opinion, as the condition involves internal processes between different body systems not readily observable to a lay person. Considering this, the Board affords greater probative weight to the VA medical opinion which finds the Veteran’s PAD disability did not occur until many years after separation from service. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). The Board also notes the Veteran’s representative has raised the issue of whether service connection is warranted on a presumptive basis. 38 C.F.R. §3.309(a). Cardiovascular-renal disease, as noted above, is on the list of diseases eligible for presumptive service connection. 38 C.F.R. § 3.309(a). The Veteran does have a diagnosis of PAD. Questions of competency notwithstanding, to the extent that the Veteran’s representative is contending that PAD may be a cardiovascular-renal disease, there is still no indication or contention that it manifested to a compensable degree within one year of separation. Finally, the Board also notes the Veteran’s representative raises the issue of the evidentiary standard for combat veterans in relation to service connection. 38 C.F.R. § 3.304(d); 38 U.S.C. § 1154(b). While the Board acknowledges the Veteran’s combat service in Korea, this exception for service connection is not applicable to the Veteran’s PAD disability. There is no evidence of record which suggests the Veteran’s PAD has its inception or is causally related to the Veteran’s combat service. Additionally, the combat presumption would only help establish the in-service element of service connection, which regardless, still does not help establish the nexus element of service connection, and the most probative evidence is showing there is no nexus. Therefore, the Board cannot rely on satisfactory lay or other evidence to establish service connection for the Veteran’s PAD disability. In summary, the most probative evidence establishes that the Veteran’s current PAD disability did not have its inception during active duty and is not otherwise causally related to service. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). REASONS FOR REMAND 1. Entitlement to service connection for a stomach disability, to include GERD, gastritis, and hiatal hernia, is remanded. The Veteran contends that his current GERD, gastritis, and hiatal hernia are a result of his service. Specifically, from his time spent in Korea where he was diagnosed with schistosomiasis. Service connection is currently in effect for ankylostomiasis, rated as 0 percent disabling. VA treatment records document a current diagnosis for GERD and hernia hiatal. See February 2017 VA examination. In accordance with the May 2018 remand instructions the Veteran was afforded a VA examination in December 2020. The VA examiner opined the Veteran’s GERD, gastritis, and hiatal hernia are less likely as not caused by or a result of active military service. The VA examiner based their rationale on the lack of evidence in the service treatment records for GERD, gastritis, and hiatal hernia. Additionally, the VA examiner opined that the GERD, gastritis, and hiatal hernia are not related to the schistosomiasis because the illnesses have different etiologies and are not pathophysiological related. The Board notes a July 1953 service treatment note shows the Veteran had the diagnosis of schistosomiasis after being treated for hookworm, although service connection is in effect for ankylostomiasis. The December 2020 VA examiner did not address the significance, if any, of schistosomiasis being present in service. Although the Board sincerely regrets the additional delay, the Veteran’s claim must be remanded before the Board is able to make a determination on the merits. As such, a medical opinion which adequately addresses all theories of entitlement regarding the Veteran’s claim of service connection for a stomach disability, to include GERD, gastritis, and hiatal hernia, to include service connection on a direct basis, and as secondary to or aggravated by service-connected ankylostomiasis must be obtained on remand. The matter is REMANDED for the following action: 1. Obtain a medical opinion from an appropriate clinician as to the nature and etiology of the Veteran’s current stomach disability, to include GERD, gastritis, and hiatal hernia. Access to the claims file should be made available to the examiner for review. After reviewing the claims file, the examiner should opine as to the following for each of the currently diagnosed disabilities: Is it at least as likely as not that the Veteran’s current stomach disability, to include GERD, gastritis, and hiatal hernia, are at all related to the Veteran’s in-service schistosomiasis noted in July 1953? Please discuss this July 1953 record. Is it at least as likely as that the Veteran’s current stomach disabilities, to include GERD, gastritis, and hiatal hernia, are related to his service-connected ankylostomiasis? Is it at least as likely as not that the Veteran’s current stomach disabilities, to include GERD, gastritis, and hiatal hernia, are aggravated (made worse) by service-connected ankylostomiasis? R. Erdheim Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Penn, 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.