Citation Nr: 21026382 Decision Date: 04/30/21 Archive Date: 04/30/21 DOCKET NO. 18-30 305 DATE: April 30, 2021 ORDER Service connection for posttraumatic stress disorder (PTSD) is denied. REMANDED The issue of service connection for a heart disability to include residuals of a heart valve replacement and ischemic heart disease (IHD), because of herbicide exposure is remanded. FINDING OF FACT The Veteran does is not diagnosed with PTSD. CONCLUSION OF LAW The criteria to establish service connection for PTSD have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1962 to August 1966. The Board of Veterans’ Appeals (Board) remanded the Veteran’s claims of service connection for lesion of the liver and a gall bladder disability in February 2021. In March 2010, the RO denied service connection for residuals of a heart valve replacement because there was insufficient evidence to show a heart disability associated with the Veteran’s service. The Veteran was informed in writing of the adverse decision and his appellate rights in March 2010. He submitted a timely notice of disagreement (NOD) in April 2010 and a Statement of the Case (SOC) was issued in September 2011. Although in his substantive appeal received later that month, the Veteran requested a Board hearing, he withdrew his request in January 2012. The claim has therefore been in appellate status since its submission. Entitlement to service connection for PTSD Service connection may be granted for current disability arising from disease or injury incurred or aggravated by active service. 38 U.S.C. § 1110. Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for PTSD requires medical evidence diagnosing the condition; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. If a stressor claimed by a veteran is related to the veteran’s fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran’s symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, “fear of hostile military or terrorist activity” means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran’s response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304(f). The Veteran contends involvement in combat during Vietnam as the source of his stressor for PTSD. As explained below, the Board makes no finding regarding the Veteran’s combat involvement because the Veteran does not have a diagnosis for PTSD. In the Veteran’s August 1966 examination for service separation, he was noted to have no relevant conditions and his psychiatric condition was noted to be normal. The Veteran indicated that he had no trouble sleeping, depression or excessive worry, and no nervous trouble of any sort. The Veteran’s PULHES profile on separation indicated that he was in excellent psychiatric health, as indicated by the “S” designator. Odiorne v. Principi, 3 Vet. App. 456 (1992) ((observing that the “PULHES” profile reflects the overall physical and psychiatric condition of the veteran on a scale of 1 (high level of fitness) to 4 (a medical condition or physical defect which is below the level of medical fitness for retention in the military service)). The Veteran’s service treatment records (STRs) are silent for relevant treatment, diagnoses, or complaints. The Veteran’s claim of service connection was received in June 2017. He reported that he had “never been treated” for PTSD and he provided no information as to a diagnosis. In VA primary care notes for treatment of other disorders, the Veteran continuously denied relevant symptoms. In May 2005, June 2006, March 2007, January 2008 and in a November 2009 treatment record, the Veteran had a negative depression screening. He specifically denied that he had “little interest or pleasure in doing things or that he felt “down, depressed, or hopeless.” In a May 2011 treatment record the Veteran’s depression and PTSD screens were negative. In an April 2013 treatment note, the Veteran was seen for a follow up visit regarding skin lesions on his forearm. During the visit, the Veteran was noted to have no anxiety or depression. In October 2017, the Veteran was afforded a VA examination. The examiner opined that the Veteran did not have PTSD or any other clinical mental health condition. The examiner noted that the Veteran endorsed some level of hyperarousal which was a symptom of the Veteran’s isolation. The examiner also noted that the Veteran denied any history of mental health treatment and noted stable overall functioning over the years, to include family relationships and successful employment. The examiner noted some symptoms of interpersonal anger and irritability but concluded that these were characterological in nature and not associated with a specific military trauma exposure. The Veteran’s medical history indicates no competent medical evidence of a PTSD diagnosis and includes negative depression and PTSD screens in November 2009 and May 2011. While non-medically trained veterans are competent to testify as to matters of subject to lay observation, the question of whether a Veteran has PTSD based on a claimed in-service stressor is a medical issue requiring medical evidence. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (“It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant”); 38 C.F.R. § 3.304(f) (specifically requiring medical evidence diagnosing PTSD). Consequently, the Veteran’s statements as to whether he has PTSD are not competent. The Veteran does not have PTSD and the claim is denied. REMAND The issue of service connection for a heart disability to include residuals of a heart valve replacement and (IHD), because of herbicide exposure is remanded. The matter is REMANDED for the following action: 1. BACKGROUND FOR THE RO ADJUDICATOR: The Veteran contends that his heart disability is the result exposure to herbicides during service. Although the Veteran underwent a VA examination in October 2017, and the examining certified nurse practitioner found that the Veteran did not have ischemic heart disease subject to a grant of presumptive service connection, medical records note treatments for various diagnoses of types of ischemic heart disease. The examination is inadequate, and a new examination is required to allow the Board to adjudicate the claim. The remand directives follow. 2. Return the file to the examiner who conducted the October 2017 VA examination. If that examiner is no longer available, schedule the examination by a medical professional qualified to diagnose and treat cardiac disorders. The entire claims file, including a copy of this Remand, must be made available to, and be reviewed by the VA examiner. If necessary, conduct a further examination and all appropriate tests, studies, and consultations should be accomplished, and all clinical findings should be reported in detail. An explanation should be given for all opinions and conclusions rendered. The VA examiner should provide an opinion regarding the following: a. The examiner must provide an opinion as to whether the Veteran currently has OR HAS HAD SINCE SUBMISSION OF THE CLAIM IN DECEMBER 2005 a diagnosis for any ischemic heart disease, to include atherosclerotic cardiovascular disease, coronary artery disease, or any acute, subacute, or evidence of an old myocardial infarction. b. The examiner should review the entire file, but his/her attention is drawn to the following: * In the Veteran’s August 1966 examination for service separation, he was noted to have no relevant conditions and his heart was noted to be normal. The Veteran indicated that he had no shortness of breath, no pain or pressure in chest, no palpitation or pounding heart, and no high or low blood pressure. The Veteran’s PULHES profile on separation indicated that he was in excellent physical health, including as to his physical capacity or stamina, as indicated by the “P” designator. * Medical records received from osteopath J. Strait indicates that in May 2001 the Veteran had a myocardial infarction; in April 2004 an irregular heartbeat; and in December 2005 a history of hypertension, aortic stenosis, coronary artery disease; *An August 2005 treatment record indicated that the Veteran had no significant CAD and his ejection fraction (EF) was noted to be normal; * A September 2005 treatment note indicated a history of mild to moderate CAD during the preceding spring. However, in a November 2005 treatment note, the Veteran was noted to have “only mild” or “nonobstructive” CAD according to an outside catheterization given over a year preceding the treatment note. A separate November 2005 treatment note reported a history of mild nonobstructive CAD from a 2001 catheterization; * In December 2005, the Veteran underwent an aortic valve replacement and pulmonary vein isolation procedure; * Office visit notes from July 2001, December 2005, March 2006, and December 2010, noted an assessment for CAD; * In a September 2010 treatment note, the Veteran was noted not to have CAD; * In a January 2011 letter, the Veteran’s physician noted that the Veteran has several medical problems, including heart problems requiring heart catherization, pacemaker and defibrillation placement, and aortic valve replacement. The physician did not provide information regarding a current diagnosis for a heart condition and did not discuss IHD; * The Veteran testified in a February 2013 hearing that he had a heart valve replacement approximately seven years earlier; * In May 2013, the Veteran was afforded a VA examination. The examiner concluded that the Veteran did not have IHD. The examiner also noted no other heart diagnoses. * In a June 2017 treatment note, the Veteran was noted to have a history of CAD. * In October 2017, the Veteran was afforded a VA examination. The examiner noted that the Veteran had an aortic stenosis status post aortic valve replacement with chronic uncontrolled atrial fibrillation. The examiner noted a diagnosis date of May 2005. The examiner indicated that there was no evidence of a cardiac event since 2014. The examiner indicated that the Veteran did not have IHD. 3. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issues on appeal. If the benefit sought on appeal remains denied, the Veteran and his representative must be provided with a Supplemental Statement of the Case (SSOC) and be afforded reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Wozniak, 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.