Citation Nr: 21030204 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 10-46 723 DATE: May 18, 2021 ORDER New and material evidence having been received, the petition to reopen the claim of service connection for coronary artery disease (CAD) is granted. Service connection for coronary artery disease (CAD) is denied. Service connection for sleep apnea is denied. Service connection for gastroesophageal reflux disease (GERD) with constipation is denied. FINDING OF FACT FINDINGS OF FACT 1. In a December 2002 rating decision, the Regional Office (RO) denied service connection for coronary artery disease. The Veteran did not file a Notice of Disagreement (NOD) and no new and material evidence was received within one year. Thus, the December 2002 rating decision became final. 2. The Veteran's CAD, sleep apnea and GERD were not caused or aggravated by his service-connected disabilities, to include the medications required for such. CONCLUSIONS OF LAW 1. The criteria for reopening the claim of service connection for a lumbar spine disability have been met. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156, 20.1103. 2. The criteria for service connection for CAD have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for GERD have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1971 to December 1975. The case is on appeal from a February 2016 rating decision. The claims most recently came before the Board in November 2020 and were remanded for further development. In the November 2020 decision, the Board also denied an effective date earlier than March 25, 2011, for the grant of service connection for a left long finger disability, service connection for neurobehavioral effects and service connection for a chronic lumbar spine disorder. The Veteran appealed the denied issues to the United States Court of Appeals for Veterans Claims (Court); however, the appeal has not been completed. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran, his representative and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). 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. A veteran seeking compensation under these provisions must establish three elements: "(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." Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. See 38 C.F.R. § 3.310. 1. Whether new and material evidence has been received to reopen the claim of service connection for CAD Applicable law provides that a final decision cannot be reopened unless new and material evidence is presented. 38 C.F.R. § 3.156. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156(a). New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. Id. The credibility of the evidence is presumed in determining whether new and material evidence has been submitted. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Moreover, in determining whether this low threshold is met, consideration need not be limited to consideration of whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. In the present case, the RO denied service connection for CAD in a December 2002 rating decision because that the Veteran's schizoaffective disorder was related to service. Thus, service connection as secondary to this disorder was denied. The evidence of record at the time of this rating decision consisted of the Veteran's service medical records, VA treatment records, VA examination, and lay statements of records. Since the December 2002 rating decision, the Veteran has been service-connected for an anxiety disorder and asserts his CAD is secondary to his service-connected anxiety disorder. Moreover, additional treatment records, VA examinations, and assertions by the Veteran and his representative have been obtain and associated with the claims file. Accordingly, the evidence is new and material and the claim of service connection for CAD is reopened. 2. Service connection for CAD. The Veteran contends that his CAD is related to his service-connected disabilities, including his anxiety disorder, and the medications required for the disorders. Following his August 2015 claim, the Veteran was afforded a September 2015 VA examination in which he was diagnosed with atherosclerotic cardiovascular disease, CAD, and stable angina. The examiner opined the heart disorder was less likely than not proximately due to the service-connected anxiety. He indicated there is no direct clinical evidence that anxiety is a risk factor for CAD. He noted the fact that the Veteran has diabetes, hyperlipidemia, obesity, and a history of drug use make these factors more likely the etiology of his CAD since all these causes have a direct link and risk for heart disease. An October 2015 medical opinion was submitted which diagnosed the Veteran with atherosclerotic cardiovascular disease and indicated he was hospitalized with chest pain in November 2014. In February 2016, the Veteran's representative submitted articles in support of the claim, including one entitled "Symptoms of anxiety and risk of coronary heart disease." The claim came before the Board in November 2017 and was remanded for further development, including a VA opinion as to the etiology of the Veteran's CAD. The Veteran was afforded a September 2018 VA opinion in which the examiner determined that his CAD is less likely than not proximately due to or the result of his service-connected disabilities. She stated the Veteran's heart disease is a disability of pathophysiology etiology. She indicated the heart muscle circulation and blood flow is supported by coronary artery vessels which can become blocked by plaque formation and require intervention to open the blockage of the artery. She stated that there is no supportive evidence that anxiety causes coronary arteries to become blocked. She indicated the blockage is from stenosis or plaque formation usually occurring from elevated cholesterol, nicotine use, obesity, family history, etc. The examiner further reported that his anxiety disorder also did not aggravate the Veteran's CAD beyond its natural progression and did not lead to his requiring angioplasty and stenting. She reviewed the internet articles submitted by the Veteran's representative and noted that they are provided for general knowledge to the public and cannot be interpreted to an individual case such as the Veteran's. An April 2020 VA opinion was obtained in which the examiner opined the Veteran's CAD is not caused or aggravated by his anxiety disorder. She indicated that relevant medical literature shows heart disease is often caused by the buildup of plaque, a waxy substance, inside the lining of larger coronary arteries and can partially or totally block blood flow in the large arteries of the heart. She stated while the cause of heart disease is often not known, anxiety is not associated with CAD. She noted that while a person who has a mental disorder may also have CAD, that does not mean that there is a direct connection between the mental condition and the CAD. She indicated there can be mutual underlying risk factors causing a mental disorder and CAD, however, association is not causality. Moreover, there is no clinical or significant medical research to support that CAD would be caused or aggravated by an anxiety condition. The Veteran's representative submitted medical articles in support of the claim and asserted in August 2020 that obesity, caused by the Veteran's service-connected disabilities, led to his CAD. The claim was remanded by the Board in November 2020 for another VA opinion to determine if the Veteran's CAD is related to a service-connected disorder, including whether obesity is an associated intermediary cause. The Veteran was afforded a February 2021 VA opinion in which the examiner determined that the Veteran's CAD is not related to his service-connected disabilities. She stated that the Veteran's CAD and the conditions of a left finger and left wrist disorders, a seizure disorder and anxiety are not medically related, and CAD is a separate entity entirely from these disorders and unrelated to them. She indicated a thorough review of the medical literature failed to demonstrate a causal relationship. She noted CAD is caused by a buildup of fatty plaques in the arteries and the causes leading to the disorder include a poor diet, lack of exercise, being overweight and smoking. She stated the Veteran's medications required for his service-connected disabilities did not cause or aggravate his CAD, and additionally, his obesity is not associated with his service-connected disabilities. She indicated obesity is primarily due to consuming more calories than the body burns off. She noted from the Veteran's documented weight listed in the record, he is clearly able to lose weight despite his service-connected disabilities and medications used to treat them. Moreover, she opined his weight gain is due to overeating and not a service-connected disability and thus, a nexus has not been established. After a review of the evidence, the Board concludes that the Veteran's CAD was not caused or aggravated by his service-connected disabilities or the medications required for the disorders. The Board finds the most persuasive evidence of record, includes the VA opinions dated September 2018, April 2020, and February 2021. These examiners thoroughly reviewed the Veteran's record and based on this review, the relevant medical literature and clinical experience, opined that the Veteran's CAD is not related to his service-connected disorders. These VA examiners supported their conclusions with well-reasoned analysis considering the relevant medical literature. The opinions are afforded significant probative weight because they are factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The Board notes there are no medical opinions of record supporting a connection between the Veteran's CAD and his service-connected disabilities or the medications required to treat those disorders. The Board acknowledges the Veteran's contentions, as well as the statements and medical literature submitted by his representative. However, as laypersons, the Veteran and his representative are not competent to provide opinions pertaining to this complex medical issue. The etiology of CAD involves a medical subject concerning an internal process extending beyond an immediately observable cause-and-effect relationship and the Veteran, as well as his representative, have not shown specialized training sufficient to render such an opinion as to the etiology of CAD. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Further, the medical literature submitted is not specific to the Veteran's own factual circumstances, and therefore, is provided less probative weight than direct medical evidence. As such, the most probative evidence of record is found to be the September 2018, April 2020, and February 2021 VA medical opinions. In sum, based on the evidence of record, the Board finds that the Veteran's CAD was not caused or aggravated by his service-connected disabilities, including the required medication. As a result, the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Therefore, service connection for CAD is not warranted. 3. Service connection for sleep apnea. The Veteran contends that his sleep apnea was caused or aggravated by his service-connected disabilities, to include his anxiety and seizure disorder, and the medication (Tegretol) required for these disabilities. Following his August 2015 claim, the Veteran was afforded a September 2015 VA examination in which he was diagnosed with obstructive sleep apnea. The examiner opined the Veteran's sleep apnea is not proximately due to his service-connected anxiety. The Veteran reports that he gets anxious and it prevents him from sleeping, thus leading to daytime somnolence. The examiner stated that there is no direct link between generalized anxiety disorder and sleep apnea. The examiner indicated that the physiology that causes hypersomnolence associated with obstructive sleep apnea is totally different than that related to anxiety disorder. He reported that the Veteran has a BMI of 36 and as such, obesity is the more likely cause of his sleep apnea. An October 2015 sleep apnea disability benefits questionnaire was submitted in which the examiner indicated the Veteran was diagnosed with sleep apnea in 2004 and the disorder leads to loud snoring and nightmares. The examiner indicated that the Veteran's depression and anxiety contribute to his sleep disorder. In February 2016, the Veteran's representative submitted articles in support of the claim, including an article from the epilepsy foundation on sleep apnea, asserting an association between epilepsy and sleep apnea syndrome. Additionally, a March 2017 correspondence from the Veteran's representative indicated sleep apnea is extremely common in those who suffer from depression, anxiety, and PTSD. The claim came before the Board in November 2017 and was remanded for further development, including a VA opinion as to the etiology of the Veteran's sleep apnea. The Veteran was afforded a September 2018 VA opinion in which the examiner determined that his sleep apnea is less likely than not proximately due to or the result of his service-connected disabilities. She stated that obstructive sleep apnea is an upper airway obstruction of airflow caused by the anatomy of the upper airway that blocks the flow of air. She opined that the etiology of obstructive sleep apnea is anatomical in nature and not related to anxiety disorder in any way. Therefore, she concluded that the Veteran's sleep apnea was not caused or aggravated by his anxiety disorder or his seizure disorder. She further noted the medication used to treat his anxiety and seizure disorders, to include Tegretol, did not cause or aggravate obstructive sleep apnea, which as noted, is an anatomical disability. The Board notes a November 2018 statement was submitted by the Veteran which asserts his sleep apnea is related to his seizure and anxiety disorders, to include the medication required for such. He stated his anxiety causes him serious problems sleeping and leads to loud snoring, narcolepsy and grinding of his teeth. He noted his reduced sleep leads to poor performance at work, increased risk of injury and other health risks. An April 2020 VA opinion was obtained in which the examiner opined that the Veteran's sleep apnea was not caused or aggravated by his anxiety disorder. She indicated that there is no clinical, medical, or significant research to support the contention that anxiety and seizures, including medication taken for the disorders such as Tegretol, leads to sleep apnea. She stated obstructive sleep apnea is a physiological condition and does not occur from medication usage. She noted the pathophysiology of sleep apnea is silent for a link to medication. The examiner stated sleep apnea and seizure disabilities are two separate and distinct conditions with two separate and distinct pathophysiologies and etiologies. She noted sleep apnea does not affect a seizure disorder and a seizure disorder does not affect sleep apnea. She indicated that there is neither evidence based medical literature nor a consensus among the general medical community at large that supports the assertion that sleep apnea is related in any way to medication taken for anxiety disorder or seizure disorder, to include Tegretol. After review of the medical articles submitted, the examiner opined some studies provide correlational research which suggests there might be a link. She stated from a scientific perspective, correlational research does not establish causation between two disorders. Moreover, findings that some people who have anxiety or seizures also have sleep apnea, does not provide a causal link or medical evidence that anxiety or seizure disorders caused sleep apnea. The examiner further indicated despite studies suggesting correlation between sleep apnea and anxiety, the current state of science and research remains inadequate to establish a causal link between the two disorders. The Veteran's representative submitted additional medical articles in support of the claim and asserted in August 2020 that obesity, caused by the Veteran's service-connected disabilities, led to his sleep apnea. The claim was remanded by the Board in November 2020 for another VA opinion to determine if the Veteran's sleep apnea is related to a service-connected disorder, including whether obesity is an associated intermediary cause. The Veteran was afforded a February 2021 VA opinion in which the examiner determined the Veteran's sleep apnea was not caused or aggravated by his service-connected disabilities, including the medications required for the disorders. She stated obstructive sleep apnea is a separate entity entirely from the service-connected disabilities, as well as the medications, and they are unrelated. The examiner noted obesity is primarily due to consuming more calories than the body burns off. She stated from the Veteran's documented weight listed in the record, he is clearly able to lose weight despite his service-connected disabilities and medications used to treat them. Moreover, she opined his weight gain is due to overeating and not a service-connected disability and thus, a nexus has not been established to obesity. The February 2021 examiner indicated the conditions of obstructive sleep apnea and a left finger and left wrist disorders, a seizure disorder and anxiety are not medically related, and sleep apnea is a separate entity entirely from these disorders. She indicated a thorough review of the medical literature failed to demonstrate a causal relationship. She noted sleep apnea is caused by a person's physical structure or medical conditions, which includes obesity, large tonsils, endocrine disorders, neuromuscular disorders, heart or kidney failure, certain genetic syndromes, and premature birth. The examiner opined a nexus, including through causation or aggravation, between sleep apnea and the service-connected disabilities or medications has not been established. After a review of the evidence, the Board finds that the Veteran's sleep apnea was not caused or aggravated by his service-connected disabilities or the medications required for the disorders. The Board determines the most persuasive evidence of record includes the VA opinions dated September 2018, April 2020, and February 2021. The opinions provided thorough rationale which adequately responded to the Veteran's contentions, as well as the evidence submitted. The examiners clearly reviewed the entire record and the opinions are based on an accurate medical history, including addressing the relevant medical research and literature. Further, these examiner's opinions contain clear conclusions with supportive opinions and as such, are entitled to significant probative weight. See Nieves-Rodriguez, 22 Vet. App. at 295. The Board acknowledges the medical opinion in support of the claim dated in October 2015. The examiner opined that the Veteran's depression and anxiety contribute to his sleep disorder. While this opinion is supportive of the claim, it provides no explanation or evidence as to why there is a connection between the Veteran's psychiatric disorder and his sleep apnea. Further, it does not adequately establish a link between his sleep apnea and service-connected anxiety disorder. In contrast are the VA opinions discussed above, from September 2018, April 2020, and February 2021. The Board finds these opinions to be more persuasive, as they addressed the evidence of record, including the Veteran's contentions and the medical literature, and provide adequate rationale supporting that the Veteran's sleep apnea is not etiologically related to his service-connected disabilities or medications. With regard to the lay statements provided by the Veteran and his representative, as lay persons they are not competent to provide a nexus opinion for this claim. The issue of the etiology of sleep apnea is medically complex and falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1372. Therefore, the Board gives more probative weight to the VA opinions of record than to the lay statements provided by the Veteran and his representative. In sum, based on the evidence of record, the Board finds that the Veteran's sleep apnea was not caused or aggravated by his service-connected disabilities, including the required medications. As a result, the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Therefore, service connection for sleep apnea is not warranted. 4. Service connection for GERD. The Veteran contends that his GERD and constipation was caused or aggravated by his service-connected disabilities, including the medication (hydrocodone) taken for such. The Veteran was afforded a September 2015 VA examination in which he was diagnosed with GERD. The examiner opined the disorder was not proximately caused by the service-connected conditions. He indicated while narcotics such as Vicodin can cause constipation, that is a side effect and not a chronic result of the disorder. The examiner stated, "it's more likely Vicodin would aggravate the symptoms of GERD and not be the cause." He indicated the Veteran's records do not show he has been on Vicodin or any similar narcotics for quite some time. He noted the Veteran does have obesity with a BMI of 36 which would be a more likely cause for GERD. In February 2016, the Veteran's representative submitted internet articles in support of the claim, including an article on Tegretol. In a September 2016 correspondence, the Veteran's representative asserts his GERD is caused by his use of Tegretol. The claim came before the Board in November 2017 and was remanded for further development, including a VA opinion as to the etiology of the Veteran's GERD. The Veteran was afforded a September 2018 VA examination in which the examiner indicated his GERD is not caused or aggravated by his service-connected disorders, including the medications to treat them. She opined narcotics can and do cause a slower motility of bowel function and thus, can cause constipation. She noted the Veteran previously used Vicodin but stopped taking the medication and continues to have constipation and GERD issues. This supports that Vicodin was not the main facet causing constipation and GERD. The examiner indicated the Veteran is on other medications for various conditions, to include GERD treatment and a side effect of these medications can be constipation. However. she indicated the Veteran's records show that he has controlled symptoms of GERD while on GERD medication and there is no evidence of chronic constipation. The examiner opined the medications used by the Veteran did not cause or aggravate his GERD. She further noted Vicodin usage can have a side effect of constipation but here, the Veteran's record supports well-controlled GERD through Omeprazole and no change in dosing or reference to flares at all. The Veteran submitted an October 2018 statement in which he disagreed with the opinion of the prior examiner. He stated his GERD is associated with his left wrist disorder, as he underwent 5 surgical operations. He additionally indicated he took oxycodone and hydrocodone medication which may have led to his GERD. The Veteran was afforded an April 2020 VA opinion in which the examiner indicated the Veteran's GERD was not caused or aggravated by his service-connected disabilities and medications. She stated the major cause of GERD is obesity and the Veteran's medical records support that he is obese, with a BMI of 35.6 presently. The examiner reported the Veteran has not taken Hydrocodone for many years and is also not presently taking Lansoprazole to control his GERD but is following a prescribed diet. Thus, she opined, the medication taken for the service-connected disabilities, including the left wrist and left long finger, such as Hydrocodone, is not the cause of the Veteran's GERD. She stated it is more likely than not that the Veteran's long-standing obesity and not following prescribed treatment is the cause of his chronic GERD. Additionally, the examiner indicated the Veteran does not have chronic constipation and medical literature supports that while narcotics cause constipation, when the narcotics stop the constipation resolves. The Veteran's representative submitted medical articles in support of the claim and asserted in August 2020 that obesity, caused by the Veteran's service-connected disabilities, led to his GERD. As noted above, the claim was remanded by the Board in November 2020 for another VA opinion to determine if the Veteran's GERD is related to a service-connected disorder, including whether obesity is an associated intermediary cause. The February 2021 VA examiner opined that the Veteran's GERD is not related to his service-connected disabilities, including the medications for such. She stated that the Veteran's medications required for his service-connected disabilities did not cause or aggravate his GERD, and additionally, his obesity is not causally related to or associated with his service-connected disabilities. She indicated obesity is primarily due to consuming more calories than the body burns off. She noted from the Veteran's documented weight listed in the record, he is clearly able to lose weight despite his service-connected disabilities and medications used to treat them. Moreover, she opined his weight gain is due to overeating and not a service-connected disability and thus, a nexus has not been established. With regard to GERD, the examiner opined that the disorder is a separate entity entirely and not medically related to his service-connected left finger disorder, left wrist disorder, seizure disorder and anxiety. Moreover, she indicated a thorough review of the medical literature failed to demonstrate a causal relationship between GERD and the service-connected conditions. The February 2021 examiner noted GERD is caused by transient lower esophageal sphincter relaxation, hypertensive lower esophageal sphincter and anatomic disruption of the gastroesophageal junction. She stated the risk factors for lower esophageal relaxation associated with GERD include obesity, bulging of the top of the stomach up into the diaphragm, connective tissue disorders and delayed stomach emptying. She further indicated factors that can aggravate acid reflux include smoking, eating large meals late at night, eating certain fatty or fried foods, drinking certain beverages, such as alcohol or coffee, and taking certain medications, such as aspirin. Therefore, the examiner noted after review of the relevant medical literature, the Veteran's GERD was not caused or aggravated by his service-connected disorders or the medications for treatment. After a review of the evidence, the Board finds that the Veteran's GERD was not caused or aggravated by his service-connected disabilities or the medications required for the disorders. As discussed in the previous issues, the Board accords the most probative weight to the September 2018, April 2020 and February 2021 VA opinions and finds these examiners adequately addressed the contentions offered by the Veteran and his representative. These examiners provided complete rationales in determining that the Veteran's GERD is not etiologically linked to his service-connected disabilities and the medications required for the disorders. The examiners thoroughly reviewed the medical evidence, as well as relevant medical literature, and provided opinions which are logical and consistent with the facts and information given. See Nieves-Rodriguez, 22 Vet. App. at 295. The Board notes there are no medical opinions of record supporting that the Veteran's GERD or constipation was caused or aggravated by his service-connected disabilities or the medications for such. The Board again takes note of the lay evidence in support, as well the medical literature submitted. However, the etiology of GERD involves a medical subject concerning an internal process extending beyond an immediately observable cause-and-effect relationship and the Veteran and his representative have not shown specialized training sufficient to render such an opinion. See Jandreau, 492 F.3d at 1372. In sum, based on the evidence of record, the Board finds that the Veteran's GERD was not caused or aggravated by his service-connected disabilities, including the required medication. As a result, the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Therefore, service connection for GERD or constipation is not warranted. S. Merrick Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Isaacs, 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.