Citation Nr: 21026553 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 20-16 029 DATE: May 3, 2021 ORDER Entitlement to service connection for a brain tumor is denied. REMANDED Entitlement to service connection for bilateral glaucoma. FINDING OF FACT The Veteran's left frontal low-grade glioma is not due to or a result of his active service. CONCLUSION OF LAW The criteria for service connection for left frontal low-grade glioma are not met. 38 U.S.C. §§ 1110, 1111, 5107(b); 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1974 to September 1998. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a February 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) which, among other things, denied service connection for glaucoma; and a July 2018 rating decision which denied service connection for, among other things, brain tumors and continued its denials of service connection for insomnia and glaucoma.. In July 2020, the Board remanded the claims for service connection for insomnia, headaches, glaucoma, and brain tumor for further development. In a January 2021 and February 2021 rating decisions, the RO granted service connection for headaches and insomnia, respectively, representing a full grant of the benefits sought on appeal. Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Therefore, the issues of service connection are no longer before the Board. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Entitlement to service connection for a brain tumor The Veteran contends that his diagnosed left frontal low-grade glioma is due to his active service. Specifically, he contends that while he was assigned to service in Turkey in 1995 to 1997, he dealt with dizziness, confusion, and loss of awareness monthly. Alternatively, he contends that a brain tumor is secondary to tinnitus, sleep apnea, refractive error, headaches, and/or glaucoma. Upon review of the evidence of record, the Board finds that service connection for a brain tumor is not warranted. Initially, the Veteran has a current diagnosis as reflected by the medical evidence of record. Post-service, medical treatment records reflect that in 2004, the Veteran began to complain of dizziness. In August 2004, the Veteran reported lightheadedness five days out of the week and slight dizziness. He reported episodes of disorientation. In November 2004, the Veteran was seen for follow up for complaints of lightheaded/dizziness. His laboratory results revealed he had some mild anemia. In December 2004, the Veteran had a head computed tomography (CT) scan following complaint of dizziness. The CT did not reveal any significant findings. He reported that his symptoms have resolved and declined a magnetic resonance imaging (MRI). In December 2006, the Veteran complained of dizziness and lightheadedness after standing for several hours. He reported palpitations and dizziness that began about a year ago. He reported that he occasionally got dizzy and lightheaded. He also complained of heart palpitations. The Veteran was advised to decrease his caffeine intake. The clinician reported that he thought his symptoms of dizziness during work are likely due to his prolonged episodes of standing. He encouraged the Veteran to keep well hydrated and take regular breaks. In January 2007, the Veteran was seen at cardiology due to palpitations, arrhythmias, and dizziness. It was recommended that he continue to avoid caffeine and other stimulants, obtain an echocardiogram for palpitations, and keep hydrated. In April 2008, the Veteran complained of dizziness while laying down at night. He did not complain of headache. In 2016, the Veteran began to complain of intermittent dizziness as well as headache. In September 2016, following an MRI of the brain, the Veteran was assessed with chronic dizziness and T2 signal hyper intensity in the left mesial forebrain region of the frontal lobe. The physician noted that he did not see any evidence that this moves into the temporal lobe. The Veteran did not have any symptoms associated with it aside from dizziness. He stated that he was uncertain if this is causing his dizziness as while it is not technically a location in the brain that they ascribe to being a dizziness center. He reported that given the diffuse nature of this lesion, certainly there could be some more nebulous relationship. He reported that the lesion is not contrast enhancing, does not suggest a high-grade tumor, and he has never had any evidence of seizure of speech arrest; thus, he concluded it is likely asymptomatic from this lesion in and of itself. In August 2017, the Veteran reported some dizziness that occurred on and off for 10 years. He reported that six months prior, he had an MRI which revealed a small lesion in the brain. Later that month, the Veteran underwent an additional MRI of the brain which revealed that the Veteran had left frontal low-grad glioma, dizziness. This evidence confirms a current diagnosis. Service treatment records (STRs) reveal that in July 1981, the Veteran was treated for dizziness, light headedness, and vomiting. In June 1990, he was seen for headaches, "stuffed up" ears, and sensitivity to light. This evidence confirms an in-service event. The question remains as to whether there is a nexus between the current diagnosis and service. Based on a review of the available records and his particular expertise, a VA examiner in December 2020 opined that the Veteran's brain tumor was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. In support, the examiner reported that a review of the medical record suggested that the Veteran's brain tumor was less likely than not is related to the in-service complaints of dizziness, headaches, and vomiting. According to the examiner, had the complaints in service been due to the Veteran's brain tumor, it would have suggested advanced enough development of the tumor to have manifested further significant symptoms and been diagnosed relatively soonnot the many years later that elapsed before the Veteran manifested significant new symptoms that led to diagnosis. At that time, the VA examiner concluded, the diagnosis was low grade glioma, which was less likely than not have begun decades earlier, as it is more likely than not to have progressed to high grade glioma in that span of time. The examiner cited a article from a medical journal in support. This VA examiner took into consideration the Veteran's in-service complaints and provided an understandable rationale for his conclusion that the Veteran's disability was not due to service. The examiner explained that the Veteran's brain tumor would have been more advanced when found if there was any correlation between the in-service complaints and his low-grade glioma. The Board is not competent to question the VA examiner's professional medical judgment or otherwise substitute its own judgment on these medical questions for that of the VA medical examiner, nor is there any reason to. See Fountain v. McDonald, 27 Vet. App. 258, 273 (2015); Monzingo v. Shinseki, 26 Vet. App. 97, 1-06 (2012). At present, the Board can find no reason to call into question or otherwise discount the probative weight of the VA examiner's opinion. The examiner's opinion is clear and unequivocal, and it was based on the relevant information, including the relevant in-service and post-service information. Moreover, the examiner's explanation is understandable, and all inferences appear to follow from the facts and information given. See Monzingo, 26 Vet. App. 97, 105-06 (2012); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Thus, overall, the VA examiner's opinion is of great probative weight and establishes why, as a medical matter, a nexus in this case is unlikely. The Veteran, including through his representative, has opined that his brain tumor is related to service. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of complex brain tumors, especially the symptoms and progression the disease, plus interpretation of complicated diagnostic medical testing. It is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the VA examiner's opinion. The Veteran has alternatively contended that the brain tumors is secondary to refractive error, headaches, glaucoma, tinnitus, and sleep apnea. The Veteran is service-connected for sleep apnea, headaches, and tinnitus. A VA examination has not been conducted as to the secondary theory. A VA examination is not warranted, however, based only on the Veteran's own conclusory, generalized statements, where there is no other supporting evidence in the record of a secondary nexus. Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010); Euzebio v. Wilkie, 31 Vet. App. 394 (2019); cf Colantonio v. Shinseki, 606 F.3d 1378, 1381-82 (Fed. Cir. 2010). Service connection on a secondary basis is not support. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim of service connection for a brain tumor. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. REASONS FOR REMAND Service connection for bilateral glaucoma is remanded. This issue is remanded for a VA addendum opinion. In November 2020, a VA examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted the treatment for glaucoma and that it was the glaucoma itself that caused the blurred vision and not vice versa. The examiner reported that the Veteran's glaucoma is termed open angle and is most likely due to hereditary and/or developed in time. The examiner identified that the Veteran's glaucoma is not angle recession which is the type that is usually due to trauma. The VA examiner appears to have misunderstood the basis of the claim. The question is not whether the Veteran's in-service complaints of blurred vision caused glaucoma. The question is whether those complaints represented the earliest manifestation of the condition. The VA examiner did not address this question. The matters are REMANDED for the following action: Obtain an opinion from an appropriate clinician regarding the Veteran's glaucoma. An in-person examination of the Veteran should be arranged if determined necessary by the appointed examiner. The examiner is asked to address whether the Veteran's glaucoma diagnosis is at least as likely as not related to an in-service injury, event, or disease, including the complaints of blurred vision. The examiner should particularly address whether the symptoms during and proximate in time to service represented the earliest manifestation of the disease. Corey Bosely Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Laroche, N. 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.