Citation Nr: A21009033 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 200605-92852 DATE: May 10, 2021 ORDER Entitlement to service connection for primary lateral sclerosis (previously claimed as spastic paraparesis) is granted. FINDING OF FACT Resolving reasonable doubt in his favor, the Veteran's primary lateral sclerosis (PLS) is a variant of amyotrophic lateral sclerosis (ALS). CONCLUSION OF LAW The criteria for service connection for PLS, as a variant of ALS, are met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.318 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1968 to June 1971. In October 2019, the Veteran submitted a VA Form 20-0995, Decision Review Request: Supplemental Claim, and requested review of a March 2019 rating decision based on new and relevant evidence. In March 2020, the agency of original jurisdiction (AOJ) issued the supplemental claim decision on appeal, which found that new and relevant evidence had been received and denied the claim based on the evidence of record at the time of that decision. In the June 2020 VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected the Hearing docket. Therefore, the Board may only consider the evidence of record at the time of the supplemental claim decision on appeal, as well as any evidence submitted by the Veteran or his representative at the November 2020 hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). Evidence was added to the claims file during a period of time when new evidence was not allowed. As the Board is deciding the claim of entitlement to service connection for PLS, it may not consider this evidence in its decision. 38 C.F.R. § 20.300. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). 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 present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The U.S. Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement to service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability, there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Entitlement to service connection for primary lateral sclerosis (PLS). The Veteran contends that service connection is warranted for PLS. Specifically, he contends that presumptive service connection is warranted for his PLS as a variant of amyotrophic lateral sclerosis (ALS). Under 38 C.F.R. § 3.318, the development of ALS manifested at any time after discharge or release from active military, naval, or air service is sufficient to establish service connection for that disease if the veteran had active, continuous service of 90 days or more. The Veteran has satisfied the service requirements for presumptive service connection for ALS. See 38 C.F.R. § 3.318(b)(3). The record reflects that the Veteran was diagnosed with spastic paraparesis, now commonly referred to as PLS, in the 1990s. In private treatment records dated in March and July 2019, the Veteran's treating clinician indicated that the Veteran continued to experience neurological symptoms of his PLS, which is a variant of ALS, and that the Veteran's disease process had progressed such that the Veteran now presented with lower motor neuron signs and symptoms, such as weakness. The clinician provided a diagnosis of PLS consistent with upper motor neuron onset of ALS. A December 2019 VA examination report reflects that the examiner provided a diagnosis of spastic paresis, a symptom of PLS, a subset of ALS. After examining the Veteran and reviewing the claims folder, the examiner explained that the Veteran has PLS, a subtype of ALS, found in 0.02 percent of ALS patients. Thus, the examiner opined that it was at least as likely as not that the Veteran's PLS was incurred in or caused by service. In a January 2020 VA addendum opinion, a second VA examiner indicated that there was evidence to support a change of diagnosis from PLS to ALS. Specifically, in July 2019, the Veteran's neurologist described a progression of the previous disease process and diagnosed the Veteran with PLS consistent with upper motor neuron onset of ALS. In several statements submitted in support of his claim, the Veteran's treating private clinician has indicated that the Veteran's PLS is a variant of ALS. Most recently, in a February 2020 letter, the Veteran's treating clinician explained that PLS affects the upper motor neurons alone, while ALS affects the upper and lower motor neurons, and that many medical specialists believe that PLS is on the ALS continuum of motor neuron degeneration. Specifically, that PLS is not a separate disease, but rather, a very slow-progressing type of ALS and that PLS has the potential to be reclassified as ALS. The Veteran also cited to several articles, including from Johns Hopkins Medicine Neurology and Neurosurgery and the National Institute of Neurological Disorders and Stroke at the National Institute of Health (NIH), that PLS is a variant of, and the rarest form of, ALS. (Continued on next page) After reviewing the evidence of record, the Board finds that the evidence is at least in equipoise as to whether the Veteran's PLS is a variant of, or form of, ALS. In such circumstances, the regulations dictate that reasonable doubt is to be resolved in the Veteran's favor. Accordingly, as the benefit-of-the-doubt rule is for application, the Board finds that the medical evidence of record shows that it is at least as likely as not that the Veteran's PLS is a variant of ALS, and warrants presumptive service connection under 38 C.F.R. § 3.318. K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Owen, 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.