Citation Nr: 21025800 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 14-35 468 DATE: April 29, 2021 ORDER Entitlement to service connection for ischemic heart disease is denied. REMANDED Entitlement to service connection for left knee condition is remanded. Entitlement to service connection for right hip condition is remanded. Entitlement to service connection for left hip condition is remanded. FINDING OF FACT The probative evidence of record does not show that the Veteran’s heart condition is related to his active duty service, to include as secondary to his service-connected posttraumatic stress disorder (PTSD). CONCLUSION OF LAW The criteria for service connection for ischemic heart disease have not been met. 38 U.S.C. §§ 1110, 1154; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in the United States Navy from April 1975 to April 1979, with additional Reserves service. In February 2018, the Veteran was provided a hearing with the undersigned Veterans Law Judge and a transcript of the proceeding is of record. The claims were brought before the Board in May 2018 and June 2020 and were remanded for further development. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service.  38 U.S.C. § 1110; 38 C.F.R. § 3.303(a).  In order to establish service connection, the record must show competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d, 1362, 1366 (Fed. Cir. 2009).  When considering such a claim for service connection, the Board must consider on a case-by-case basis, the competence and sufficiency of lay evidence offered to support a finding of service connection. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (quoting Jandreau v. Nicholson, 492 F.3d 1372, 1377 Fed. Cir. 2007)).  The mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010).  Entitlement to Service Connection: Heart Disease The Veteran contends that his heart condition is related to his active duty service, to include as secondary to his service-connected PTSD. As an initial matter, the Board acknowledges that the Veteran has been diagnosed with myocardial infarction.  Further, the Veteran’s service records show he had high blood pressure in 1977 and the Veteran is service-connected for PTSD.  Thus, the issue turns upon whether there is evidence of a nexus between the claimed in-service event or injury and the present disability, to include whether his condition is due to and/or aggravated by his service-connected PTSD.  See Sheldon v. Principi 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Board finds there is not. In February 2016, the Veteran was provided a VA examination. The examiner opined that the Veteran’s heart disease was less likely than not proximately due to or the result of the Veteran’s service-connected PTSD. The examiner rationalized that PTSD is a mental health condition that causes nightmares, anxiety, and flashbacks. However, myocardial infarction is caused by atherosclerosis of a coronary artery. The examiner lastly noted that PTSD is not a coronary condition and does not cause obstruction of a coronary artery. In January 2020, the Veteran attended another VA examination. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service event or injury. The examiner rationalized that the Veteran’s service treatment records document occasional blood pressure elevation; however, there is no evidence of sustained hypertension and there is no diagnosis of hypertension during his active duty service. The examiner explained that the Veteran’s medical records do not document a diagnosis of hypertension until 2013 during a primary care visit. The examiner additionally opined that the Veteran’s condition was less likely than not proximately due to or the result of the Veteran’s service-connected PTSD. The examiner rationalized that well-accepted risk factors for atherosclerosis result in ischemic heart disease, include smoking, hyperlipidemia, hypertension, diabetes, and family history. The examiner stated that PTSD is not a well-accepted risk factor for the development of atherosclerosis, which results in ischemic heart disease. Most recently, a VA opinion was obtained in July 2020. The examiner opined that that Veteran’s condition was not aggravated by his service-connected PTSD. The examiner rationalized that documented well-established significant risk factors for the Veteran’s myocardial infarction are hyperlipidemia, hypertension, and family history. The examiner explained that PTSD is not an established significant risk factor for myocardial infarction per peer-reviewed medical literature, and therefore, did not influence the development of the Veteran’s myocardial infarction to any significant extent compared to his hyperlipidemia, hypertension, and positive family history. The examiner further found that the Veteran’s available treatment medical records do not show ischemic heart disease to have deviated abnormally outside of its normal trajectory. The examiner provided that during a recent VA heart examination, no other invasive treatment or complications pertaining to his ischemic heart disease condition are noted that would suggest that his heart condition significantly deteriorated or evolved beyond a natural progression. The examiner lastly concluded that since the contention of aggravation beyond its natural progression has not been met, the Veteran’s PTSD did not exert influence to aggravate his ischemic heart disease beyond its natural progression. The Board notes that VA treatment records and private medical records show treatment for the Veteran’s heart condition; however, none of the records relate the Veteran’s condition to his active duty service. Moreover, as discussed in the Board’s May 2018 decision, the Board has considered the private opinion submitted in January 2017. However, the physician opined that it was possible the Veteran’s anxiety induced a hypertensive crisis that led to his coronary syndrome and as previously noted, such a speculative opinion is not probative, but rather is inconclusive. See Warren v. Brown, 6 Vet. App.4, 6 (1993) (stating that a physician’s statement framed in terms such as “may,” “could,” or “possible” is not probative); see also Tirpak v. Derwinski, 2Vet. App.609, 611 (1992) (statement that outcome “may or may not” have been different is speculative). Thus, the speculative opinion does not provide probative or persuasive evidence to support the Veteran’s claim. Therefore, the Board finds the February 2016, February 2020, and July 2020 VA opinions to be of significant probative value in determining the Veteran’s heart condition is not related to his active duty service or his service-connected PTSD.  The Board notes that the probative value of medical opinion evidence is based on the medical experts’ personal examination of the patient, their knowledge, and skill in analyzing the data, and their medical conclusion.  As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator.  Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993).  Here, the examiners showed knowledge of the Veteran’s background and based the opinions on the Veteran’s lay contentions, the physicians’ medical knowledge, and examinations of the Veteran.  Additionally, complete and thorough rationales were provided for the opinions rendered and are consistent with the medical evidence of record. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993).    The Board has also considered presumptive service connection under 38 C.F.R. § 3.309(a) for cardiovascular disease and service connection based on a continuity of symptomatology under 38 C.F.R. § 3.303(b); however, the probative evidence does not indicate that the Veteran’s heart disability or hypertension manifested within a year of separation of service or that it occurred continuously since discharge from service, nor is the Veteran contending that his heart disability manifested within a year of separation of service or that it occurred continuously since discharge from service. Therefore, presumptive service connection and service connection based on continuity of symptomatology are not warranted. The Board acknowledges the Veteran’s assertions that his heart condition is related to his active duty service.  The Board recognizes that lay persons are competent to provide medical opinions on some medical issues.  See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011).  However, although the Veteran is competent to report his symptoms, any opinion regarding whether any disability is related to his military service, to include as secondary to his service-connected PTSD, requires medical expertise that the Veteran has not demonstrated since heart disabilities can have many causes.  See Jandreau v. Nicholson, 492 F.3d 1372, 1376 (2007).  In light of the foregoing, the Board concludes that the preponderance of evidence is against the claim and the benefit of the doubt doctrine is not for application.  See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001).   REASONS FOR REMAND Although the Board sincerely regrets further delay, another remand is necessary to afford the Veteran every possible consideration. Entitlement to Service Connection: Left Knee and Bilateral Hip Conditions The Veteran contends that his left knee condition and bilateral hip conditions are related to his active duty service, to include his left knee condition as secondary to his service-connected right knee condition, and his bilateral hip conditions as secondary to his service-connected back disability. In June 2020, the Board remanded the Veteran’s claims for further development. Specifically, the Board found that the January 2020 VA opinions on the Veteran’s left knee and bilateral hip conditions were inadequate to fairly adjudicate the claims due to the opinions only discussing whether the claimed conditions were caused by the service-connected disabilities and not providing a separate rationale for whether the conditions were aggravated by the service-connected disabilities. However, the addendum the opinions obtained in August 2020 still do not provide rationales for whether the service-connected disabilities aggravate the Veteran’s claimed conditions. In fact, the rationales provided are the same exact rationales from the February 2020 VA opinions. The Board again notes that a VA opinion must provide separate rationales for both causation and aggravation in a secondary service connection claim. See Atencio v. O’Rourke, 30Vet. App.74 (2018). Therefore, the Board finds that a remand is required in order to obtain new opinions as to the etiologies of the Veteran’s claimed conditions. McLendon v. Nicholson, 20 Vet. App. 79 (2006) The matters are REMANDED for the following action: Send the claims file to an appropriate examiner other than the examiner who provided the January and August 2020 opinions, if possible. If the examiner determines the requested opinion cannot be provided without an examination, then such examination should be scheduled and may be conducted via telehealth or similar service during the social distancing restrictions of the COVID-19 pandemic. A copy of this remand should be made available to the examiner. Following a review of the entire record, the Veteran’s competent lay statements, as well as the Veteran’s report regarding the onset and progression of his current symptomatology, the examiner should opine as to the following: a) Is it at least as likely as not (50 percent probability or more) that the Veteran’s left knee disability is aggravated by his service-connected right knee disability? “Aggravation” is defined as any worsening beyond the natural progression of the disability. b) Is it at least as likely as not (50 percent probability or more) that the Veteran’s bilateral hip conditions are aggravated by his service-connected back disability? “Aggravation” is defined as any worsening beyond the natural progression of the disability. In offering any opinion, the examiner must consider the full record, to include the lay statements regarding in-service incurrence, and the opinion should reflect such consideration. A clearly-stated rationale for any opinion offered should be provided. JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Negron, 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.