Citation Nr: 21029190 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 15-10 759 DATE: May 12, 2021 ORDER Entitlement to service connection for bilateral breast disability is denied. Entitlement to service connection for coronary artery disease is denied. FINDINGS OF FACT 1. The preponderance of evidence weighs against finding that the Veteran's bilateral breast disability is etiologically related to service or secondary to service-connected disability. 2. The preponderance of evidence weighs against finding that the Veteran's coronary artery disease is etiologically related to service, to include as secondary to service-connected right shoulder and bilateral knee disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral breast disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307. 3.309, 3.310. 2. The criteria for service connection for coronary artery disease have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from January 1980 to February 1993, and October 2005 to February 2006. These matters come before the Board of Veterans' Appeals (Board) on appeal from January 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Anchorage, Alaska. In September 2015, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In June 2018, the Board remanded the claims to attempt to obtain private treatment records and obtain VA examinations with medical opinions that address direct and secondary service connection. To date, the VA has not received a response to February 2019 letter requesting authorization for release of private records. Service Connection Service connection is granted for any current disability that is the result of a disease contracted or an injury sustained while on active duty service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for a disease diagnosed after discharge, where all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38C.F.R. § 3.303(d). Service connection requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection is permissible, as well, on a secondary basis for disability that is proximately due to, the result of, or chronically aggravated by a service-connected condition. See 38 C.F.R. § 3.310 (a) and (b). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish entitlement to service connection on this alternative secondary basis, there must be: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Certain chronic diseases 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). 1. Entitlement to service connection for breast disability. The Veteran asserts that her breast disability is related to lymph node pain and an infection during service. She testified that she had bilateral breast pain, lymph node pain, and a lump in her breast during service in November 1991. Additionally, she credibly testified that she suffered an injury to her left breast due to an in-service sexual assault. She further stated that in 1992, she was referred for a breast reduction. See September 2015 Hearing Transcript. July 1983 service treatment record (STR) notes complaints of breast pain and tenderness. August 1992 service treatment record (STR) notes complaints of left axillae pain. The assessment was extramammary breast tissue left axillae. The breast examination was normal. Aril 1993 VA examiner diagnosed the Veteran with a "probable fibrocystic disease" of the breast with hormone effect on the left breast. The Veteran had a mammogram finding in her left breast in 2003. She did not have her next mammogram until 2010. The nodule was noted to be stable. She also had an MRI of her shoulder in April 2010 that showed "axillary lymphadenopathy". On follow-up chest CT, the "lymphadenopathy" was felt to be bilateral. There was also a left upper bilateral breast finding. A mammogram showed a stable density. Ultrasound showed a "mixed echogenicity circumscribed mass". The findings were felt to be benign. See July 2013 private treatment note. July 2010 private treatment note showed normal appearing lymph nodes. October 2010 private treatment record shows a diagnosis of bilateral mastodynia. Bilateral breast pain and tenderness was also noted. The Veteran underwent a breast reduction surgery in December 2013. See December 2013 Private Operative Report. The Veteran underwent a VA examination in May 2019, which showed a diagnosis of fibrocystic/nodular breasts, a developmentally dense/nodular breast tissue with extramammary breast tissue, status post breast reduction. The examiner opined that the condition claimed was less likely than not incurred in or caused by the claimed in-service event, injury or illness. The examiner further opined that the condition claimed is less likely than not proximately due to, the result of, or aggravated by the Veteran's service-connected shoulder and knee disabilities. The examiner stated that fibrocystic/nodular breasts is a developmental condition of the breast tissue consisting of dense/nodular/cystic breast tissue. The examiner noted that the evidence of record is compatible with fibrocystic dense breast, a congenital/developmental condition of the breast causing pain and tenderness of breast tissue in addition to having extramammary breast tissue, a naturally occurring condition. The examiner stated that referral to surgery for possible breast reduction while in service was based on extramammary glandular tissue (non-pathological) and service treatment records are silent in regard to pathological breast disease during military service. Additionally, the examiner stated that records document peri-menstrual sensitivity of glandular breast tissue, a normal physiological response to the female hormonal cycle. In a May 2020 medical opinion, the examiner stated that the Veteran's bilateral breast reduction surgery was less likely (less than 50 percent probability) due to or the result of the fibrocystic/nodular breasts and associated pain noted in STRs and/or other events during military service. The examiner opined that the Veteran's breast reduction surgery was due to the direct result of elective surgery. The examiner stated that October 2012 clinical note documents breast tissue that is naturally-nodular/fibrocystic breast tissue (recommends f/w with mammographic density) and notes the Veteran's interest in having a "breast reduction and losing weight." The examiner noted that having fibrocystic/nodular-type or dense breast tissue does not represent a clinical indication for bilateral breast reduction, and all events associated with elective breast reduction and post-service medical conditions are distinct, separate and unrelated to military service. Based on the above, the Board concludes that the preponderance of the evidence weighs against finding that the Veteran's bilateral breast disability began during service or is otherwise related to an in-service injury, event, or disease. Although, as the Veteran contends, there is evidence of bilateral fibrocystic breast in April 1993, it has not been shown to be related to a current bilateral breast disability. While the Veteran is competent to report having experienced in-service pain and tender breasts since service, she is not competent to determine that these symptoms resulted in her current bilateral breast disability or that it is attributable to service. The issue of establishing nexus based on etiology is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Further, the May 2020 medical opinion was that the Veteran's bilateral breast disability is less likely (less than 50 percent probability) due to or the result of the fibrocystic/nodular breasts and associated pain noted in STRs and/or other events during military service. The examiner further opined that the condition claimed is less likely than not proximately due to, the result of, or aggravated by the Veteran's service-connected shoulder and knee disabilities. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Consequently, the Board gives more probative weight to the examiner's opinion, as it is supported by rationale discussing the medical evidence. The Veteran, through her representative, has contended that although the examiner alleged the condition has a direct connection to her obesity or weight gain, the examiner failed to discuss the etiology of the weight gain or obesity and whether there is a relationship to her service. See May 2021 Appellate Brief. However, although the examiner stated that the Veteran was interested in having a breast reduction and losing weight, there is no indication from the examiner that the Veteran has a current breast disability that is related to obesity or weight gain. The United States Court of Appeals for Veterans Claims (CAVC) has explained that to reasonably raise the theory of secondary service connection via obesity as an intermediate step, there must be some evidence in the record that draws an association or suggests a relationship between the Veteran's obesity, or weight gain resulting in obesity, and a service connected disability. Conversely, incidental references to obesity, or weight gain resulting in obesity, are insufficient to reasonably raise this theory of entitlement. Garner v. Tran, No. 18-5865. Therefore, a remand is not warranted on this basis. Although the evidence shows in-service treatment for bilateral breast pain, the record does not otherwise show that the Veteran had a chronic disability which began during service or manifested to a compensable degree following service. As the preponderance of the evidence weighs against the Veteran's claim, service connection for a bilateral breast disability must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for coronary artery disease. The Veteran asserts that her coronary artery disease (CAD) is related to service, to include as secondary to her service-connected right shoulder disability and bilateral knee disabilities. She testified that procedural issues stemming from her shoulder and knee disabilities resulted in her inability to re-enlist, which contributed to a stress-related heart attack or caused or aggravated a heart condition. See September 2015 Hearing Transcript. December 1990 service treatment records (STR) notes complaints of chest pains for the previous two weeks. The condition was diagnosed as Costochondritis and described as an acute and transitory musculoskeletal condition. Cardiac evaluation was reported as normal. October 1992 separation examination noted palpation or pounding heart. The Veteran's STRs otherwise show normal heart. January 1993 STR shows the Veteran complaints of chest pains. However, testing was negative for heart disease and no heart condition was shown. April 1993 separation examination showed normal EKG. August 2011 Critical care note documented chest pains and an inferior myocardial infarction. The Veteran denied prior cardiac history and reported that she started having chest pain the night before, described as "a brick on her chest." The note documented that she is a smoker and has a family history of coronary artery disease and has a stent. She underwent a Percutaneous Transluminal Coronary Angioplasty PTCA and drug-eluting stents to the right coronary artery, that was described as a success with reduction in stenosis from 100 percent to 0 percent. September 2011 ECHO study was reported as normal. August 2012 VA treatment record noted that she had multiple risk factors. The cardiologist noted there was no recurrent chest pain and MRI shows small amount of ischemia. The treatment records noted that she has no anginal chest pains or exercise intolerance. August 2016 VA treatment note showed moderate to severe atherosclerosis in most vessels of the aorta. May 2019 examiner stated that Clinical notes show multiple risk factors for the development of coronary artery disease; obesity with body mass (BMI) fluctuating between 38.1 to 42 and physician monitored participation in weight management and exercise program (MOVE program); Hyperlipidemia; strong family history of CAD; and life-time smoker. The Veteran underwent a VA examination in May 2019, which showed a diagnosis of coronary artery disease with an onset described as gradual. The examiner opined that the condition claimed was less likely than not incurred in or caused by the claimed in-service event, injury or illness. The examiner further opined that the claimed condition was less likely than not proximately due to, the result of or aggravated by the Veteran's service-connected disabilities. The examiner stated that clinical records show the Veteran's coronary artery disease is of multifactorial etiology and has the following risk factors including obesity with body mass (BMI) fluctuating between 38.1 to 42 weight management; hyperlipidemia; strong family history of CAD; and chronic smoker. The examiner concluded that the Veteran's diagnosis is due to the direct result of her multiple risk factors for the development of CAD. The Veteran, through her representative, has contended that although the examiner alleged the condition has a direct connection to her obesity or weight gain, the examiner failed to discuss the etiology of the weight gain or obesity and whether there is a relationship to her service. See May 2021 Appellate Brief. However, the Board notes that obesity is not a disability capable of service connection and, as such, does not, by itself, warrant consideration of etiology or relationship to service. To the extent that the Veteran and her representative contend that there is an intermediary relationship between the Veteran's obesity and her CAD, the contention does not suggest or provide evidence supportive of a service-connected disability to which obesity is related and as required for this theory of entitlement. To reasonably raise the theory of secondary service connection via obesity as an intermediate step, there must be some evidence in the record that draws an association or suggests a relationship between the Veteran's obesity, or weight gain resulting in obesity, and a service connected disability. Conversely, incidental references to obesity, or weight gain resulting in obesity, are insufficient to reasonably raise this theory of entitlement. Here, although the examiner stated that the Veteran's CAD is likely due to multiple factors, to include obesity, the examiner does not indicate there is a relationship between obesity and a service-connected disability and the Veteran and her representative, similarly, have not provided competent evidence of any association in this regard. Therefore, a remand is not warranted on this basis. After careful review of the claim, the Board concludes that the evidence of record weighs against finding that the Veteran's CAD is related to service, to include as caused or aggravated by service-connected shoulder and knee disabilities. The examiner opined that the Veteran's CAD is less likely than not caused by or incurred in service, or proximately due to or aggravated by service-connected shoulder and knee disabilities. Instead, the examiner linked the Veteran's CAD to other factors noted in her medical history, none of which include in-service event, injury or disease or service-connected disabilities. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data based on the evidentiary record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran maintains that her CAD is related to service, to include secondary to shoulder and knee disabilities. Although the Veteran is credible as to her testimony regarding symptoms, there is no indication that she has the training or expertise to competently opine on the etiology of her CAD. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). Service connection is also not warranted for CAD as a chronic disability under 38 C.F.R. § 3.307(a), as the competent medical evidence of record does not demonstrate that the Veteran's CAD was noted as chronic in service or manifested to a compensable degree in service or within the one year presumptive period. Although chest pains were noted in service, separation examination was normal, the myocardial injury did not occur until 2011five years post service, and there was no finding of heart disease or condition until 2019 diagnosis of CAD. See 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Accordingly, as the preponderance of the evidence weighs against service connection, this claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Nathaniel J. Doan Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Wilson, 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.