Citation Nr: 21025709 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 17-49 210 DATE: April 28, 2021 ORDER Entitlement to service connection for heart problems is denied. Entitlement to service connection for right wrist pain is denied. Entitlement to service connection for right leg pain is denied. Entitlement to service connection for back pain and side pain is denied. Entitlement to service connection for bilateral foot pain is denied. Entitlement to service connection for unsteady gait and dizzy spells is denied. Entitlement to service connection for gastroesophageal reflux disease (GERD) is denied. Entitlement to service connection for prostate cancer is denied. Entitlement to service connection for dental problems is denied. Entitlement to service connection for throat pain and bumps is denied. Entitlement to service connection for hemorrhoids is denied. REMANDED Entitlement to service connection for headaches is remanded. Entitlement to service connection for acquired psychiatric disorder to include posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for rash on face and arms is remanded. Entitlement to service connection for bilateral eye pain is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that heart problems began during active service or are otherwise related to an in-service injury or disease. 2. The preponderance of the evidence is against finding that right leg pain began during active service or is otherwise related to an in-service injury or disease. 3. The preponderance of the evidence is against finding that back pain and side pain began during active service or is otherwise related to an in-service injury or disease. 4. The preponderance of the evidence is against finding that bilateral foot pain began during active service or is otherwise related to an in-service injury or disease. 5. The preponderance of the evidence is against finding that unsteady gait and dizzy spells began during active service or is otherwise related to an in-service injury or disease. 6. The preponderance of the evidence is against finding that GERD began during active service or is otherwise related to an in-service injury or disease. 7. The preponderance of the evidence is against finding that prostate cancer began during active service or is otherwise related to an in-service injury or disease. 8. The preponderance of the evidence is against finding that dental problems began during active service or is otherwise related to an in-service injury or disease. 9. The preponderance of the evidence is against finding that hemorrhoids began during active service or is otherwise related to an in-service injury or disease. 10. The preponderance of the evidence of record is against finding a current diagnosis of throat pain and bumps at any time during or approximate to the pendency of the claim. 11. The preponderance of the evidence of record is against finding a current diagnosis of right wrist pain at any time during or approximate to the pendency of the claim. CONCLUSIONS OF LAW 1. The criteria for service connection for heart problems are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for right leg pain are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for back pain and side pain are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for bilateral foot pain are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for unsteady gait and dizzy spells are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for GERD are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for service connection for prostate cancer are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for service connection for teeth problems are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 9. The criteria for service connection for hemorrhoids are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 10. The criteria for service connection for throat pain and bumps are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 11. The criteria for service connection for right wrist pain are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from May 1965 to May 1967. In August 2020, the Board remanded the case for further development, which is completed. Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303. “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. Shineski, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). 1. Entitlement to service connection for heart problems, right leg pain, back and side pain, bilateral foot pain, unsteady gait and dizzy spells, GERD, prostate cancer, and hemorrhoids The Board concludes that while the Veteran has diagnoses related to heart problems, right leg pain, back and side pain, bilateral foot pain, unsteady gait and dizzy spells, GERD, prostate cancer residuals, and hemorrhoids, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. The Veteran has generally contended that his conditions begin in service and progressively worsened, but he has not provided any specific statements or arguments regarding any in-service injuries, events or diseases related to the above listed conditions. The service treatment records are also silent as to any complaints, treatments or diagnoses related to the listed conditions. While the Veteran may believe his heart problems, right leg pain, back and side pain, bilateral foot pain, unsteady gait and dizzy spells, GERD, prostate cancer residuals, and hemorrhoids are related to service, the record does not contain evidence to support this allegation. There is no evidence of an in-service injury, event or disease pertaining to heart problems, right leg pain, back and side pain, bilateral foot pain, unsteady gait and dizzy spells, GERD, prostate cancer residuals, and hemorrhoids. The VA’s duty to provide a VA examination is not triggered in this case. In determining whether VA’s duty to assist requires a VA medical examination or medical opinion, four factors are for consideration: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A (d) (2012); 38 C.F.R. § 3.159 (c)(4) (2017); see McLendon v. Nicholson, 20 Vet. App. 79 (2006). As the evidence of record does not establish that the Veteran’s claimed conditions manifested during service or are related to service, VA examinations or opinions are not necessary. The Board notes that in a correspondence dated June 2016 the Veteran stated that he worries that he “could have been exposed to agent orange as equipment that could possibly have been exposed was shipped back and forth from that area to ours.” See Statement in Support of Claim for PTSD January 2016. The Board finds this vague, overly broad does not trigger the requirement for further evidentiary development as the Veteran merely muses about possible exposure without any other evidence. See Gobber v. Derwinski, 2 Vet. App. 470, 472 (1992) ("The 'duty to assist' is not a license for a 'fishing expedition' to determine if there might be some unspecified information which could possibly support a claim"). Therefore, the claims of entitlement to service connection for heart problems, right leg pain, back and side pain, bilateral foot pain, unsteady gait and dizzy spells, GERD, prostate cancer residuals, and hemorrhoids are denied. 2. Entitlement to service connection for dental problems The Veteran contends entitlement to service connection for dental problems. Under VA law, compensation is only available for certain types of dental and oral conditions, which are set under 38 C.F.R. § 4.150. Disability compensation and VA outpatient dental treatment may be provided only for certain specified types of service-connected dental disorders. For other types of service-connected dental disorders, the claimant may receive treatment only and not compensation. 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 4.150, 17.161. Dental disabilities that may be awarded compensable disability ratings set forth in 38 C.F.R. § 4.150 include chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, loss of the maxilla, nonunion or malunion of the maxilla, limited temporomandibular motion, loss of the ramus, loss of the condyloid or coronoid processes, loss of the hard palate, loss of teeth due to the loss of substance of the body of the maxilla or mandible and where the lost masticatory surface cannot be restored by suitable prosthesis, when the bone loss is a result of trauma or disease but not the result of periodontal disease. Under 38 C.F.R. § 3.381, treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are to be considered service-connected solely for the purpose of establishing eligibility for outpatient dental treatment as provided in 38 C.F.R. § 17.161. The Board finds that the evidence weighs against a current dental disability eligible for service connection as the medical evidence does not reveal the Veteran experienced dental trauma or disease (such as osteomyelitis) as a result of active duty causing a loss of substance of body of the maxilla or mandible resulting in a loss of teeth. Rather, the evidence indicates current diagnoses of dental caries and tooth decay, which are not a dental disability eligible for service connection under VA regulations. Furthermore, the service records only reflect routine dental care. As such, the claim for entitlement to service connection for teeth problems is denied. 3. Entitlement to service connection for throat pain and bumps and right wrist problem The Board concludes that the Veteran does not have a current diagnosis of throat pain and bumps or right wrist problem and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). Review of the medical treatment records confirms that the evidence of record does reveal complaint, treatments or diagnoses related to the throat or wrist. To the extent that the Veteran alleges he has throat and/or right wrist problems this allegation is without probative value as the record does not establish that the Veteran has the specialized knowledge to provide such diagnosis. Therefore, the Board finds the evidence insufficient to establish a current disability. Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer v. Derwinski, 3 Vet. App. 223, 255 (1992). In the absence of proof of a present disability there can be no valid claim. Id. As such, the preponderance of the evidence is against the claim for service connection for throat pain and bumps and right wrist condition. REASONS FOR REMAND 1. Entitlement to service connection for headaches The VA has a duty to assist, which includes providing a medical examination when necessary to make a decision on a claim. 38 C.F.R. § 3.159(c)(4)(i) (2017). Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and clear and unmistakable evidence demonstrates that the injury or disease was not aggravated by service. 38 U.S.C. § 1111 (2012); 38 C.F.R. § 3.304 (b) (2017); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004) (outlining the presumption of soundness). If a preexisting disorder is noted upon entry into service, the Veteran cannot bring a claim for service incurrence for that disorder, but he may bring a claim for service-connected aggravation of that disorder. Paulson v. Brown, 7 Vet. App. 466, 468 (1995). A preexisting disorder will be considered to have been aggravated by service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progression of the disease. 38 U.S.C. § 1153 (2012); 38 C.F.R. § 3.306 (a) (2017). It is the Veteran who bears the burden of establishing aggravation under 38 U.S.C. § 1153. Jensen v. Brown, 19 F.3d 1413 (Fed.Cir.1994). The Veteran’s induction examination dated May 1965 reports a history of frequent and severe headaches with the physician noting a possible diagnosis related to headaches. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). As such, an opinion on whether the Veteran’s headaches were a preexisting condition, and whether it was aggravated by his active duty service is needed. 2. Entitlement to service connection for acquired psychiatric condition, to include PTSD The Veteran provided several statements alleging that a soldier in his battalion was killed when a Jeep turned over on him. A May 2013 Formal Finding concluded there was insufficient information to corroborate the stressor and allow for meaningful research. The Veteran provided additional details including the location, year and the battalion of the soldier. The September 2013 rating decision concluded that research revealed no jeep accidents within the alleged timeframe; however, a formal finding detailing the research and its results are not of record. As the Veteran provided sufficient details to allow for meaningful research, a remand is necessary for additional attempts to verify the alleged stressor, to include a memorandum detailing all findings. 3. Entitlement to service connection for rash on face and arms and bilateral eye pain The VA has a duty to assist, which includes providing a medical examination when necessary to make a decision on a claim. 38 C.F.R. § 3.159(c)(4)(i) (2017). The record contains sufficient evidence to trigger the VA’s duty to assist by providing a VA examination as the evidence includes current diagnoses and indication of treatment and/or diagnoses related to skin and eyes in-service. However, a VA examination to discuss the nature and etiology of the Veteran’s rash and bilateral eye condition has not been provided. Therefore, a VA examination for opinions to determine the etiology of the Veteran’s rash and bilateral eye pain is warranted. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The matters are REMANDED for the following action: 1. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. 2. Acquire updated VA and/or private treatment records. If such records are unavailable, the Veteran’s claim file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 3. Schedule the Veteran for a VA examination with a medical professional with appropriate expertise to determine the nature and etiology of headaches. The examiner should review the Veteran’s claims file. Based on a review of the record, the examiner must address the following: (a.) Is it clear and unmistakable (i.e., undebatable) that the Veteran had a headache condition prior to commencement of active duty in May 1965? The examiner must consider and discuss the May 1965 separation examination notation regarding headaches. (b.) If so, is it clear and unmistakable that the preexisting headache condition was not aggravated (i.e., permanently worsened) during the Veteran's military service? (c.) Is it at least as likely as not (i.e., probability of 50 percent or greater) that a current headache condition had its onset during service, or is related to a disease, event, or injury during service? The examiner should elicit a full history from the Veteran and consider and address any lay statements of record. If there is a medical basis to support or doubt the history provided, the examiner should provide a fully reasoned explanation. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. The examiner should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 4. Attempt to verify the Veteran’s reported stressors of a fellow soldier in his battalion being killed in a Jeep accident. Provide all findings in a detailed memorandum, to include a thorough rationale if a reported stressor is not verifiable. If additional information is needed from the Veteran in relation to this incident, request the same. 5. After completing the above, schedule the Veteran for a VA examination with a VA psychiatrist or psychologist to determine the nature and etiology of any acquired psychiatric disorder, to include PTSD. The claims file should be made available to the examiner in conjunction with the examination. Any medically indicated tests should be accomplished, and all pertinent symptomatology and findings must be reported in detail. The examiner should list all psychiatric disorders present during the time period of the claim. With regard to each identified acquired psychiatric disorder present during the claim, the VA examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that any diagnosed psychiatric disorder originated during or is otherwise etiologically related to the Veteran’s military service. If PTSD is diagnosed, the specific stressors giving rise to the condition must be identified. In providing the requested opinions, the examiner is advised that the term "at least as likely as not" does not mean within the realm of possibility, but that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. The examiner should elicit a full history from the Veteran and consider and address any lay statements of record. If there is a medical basis to support or doubt the history provided, the examiner should provide a fully reasoned explanation. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. The examiner should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 6. Schedule the Veteran for a VA examination with a medical professional with appropriate expertise to determine the nature and etiology of any diagnosed rash or eye conditions. The examiner should review the Veteran’s claims file. Based on a review of the record, the examiner must address the following: List all skin and eye conditions present during the time period of the claim. With regard to each identified condition present during the claim, the VA examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that any diagnosed skin or eye condition originated during or is otherwise etiologically related to the Veteran’s military service. In providing the requested opinions, the examiner is advised that the term "at least as likely as not" does not mean within the realm of possibility, but that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. The examiner should elicit a full history from the Veteran and consider and address any lay statements of record. If there is a medical basis to support or doubt the history provided, the examiner should provide a fully reasoned explanation. (Continued on the next page)   A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. The examiner should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Prinsen, Samantha 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.