Citation Nr: 22014464 Decision Date: 03/14/22 Archive Date: 03/14/22 DOCKET NO. 17-64 768 DATE: March 14, 2022 ORDER Service connection for polycystic kidney disease is denied. REMANDED Entitlement to service connection for gout of the bilateral wrists, fingers, and toes, as secondary to nephrolithiasis, is remanded. FINDING OF FACT The Veteran's polycystic kidney disease is a congenital disease that was clearly and unmistakably not aggravated beyond its natural progression in service. CONCLUSION OF LAW The criteria for entitlement to service connection for polycystic kidney disease have not been met. 38 U.S.C. §§ 1110, 1111, 1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1991 to February 1999. The matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2017 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in April 2021. The hearing transcript is of record. Entitlement to service connection for polycystic kidney disease is denied. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). 1. Congenital or developmental defects are not "diseases or injuries" within the meaning of applicable statutes and regulations. 38 C.F.R. § 3.303(c). However, where during service a congenital or development defect is subject to a superimposed injury or disease, service connection may be warranted based on aggravation. VAOPGCPREC 82-90 (July 19, 1990), published at 56 Fed. Reg. 45,711 (1990) (a reissue of General Counsel Opinion 01-85 (March 5, 1985)). The VA General Counsel's opinion notes that there is a distinction under the law between a congenital or developmental "disease" and a congenital "defect" for service connection purposes in that congenital diseases may be recognized as service connected if the evidence as a whole shows aggravation in service within the meaning of VA regulations. VAOPGCPREC 82-90. A congenital abnormality that is subject to improvement or deterioration is considered a "disease," while a congenital abnormality that is more or less stationary in nature and not considered capable of improving or deteriorating is considered a "defect." Id. Here, the record shows that the Veteran has a current diagnosis of polycystic kidney disease (PKD). See February 2017 VA examination; private medical treatment records received by VA in June 2017. Thus, the first question for the Board is whether the Veteran's PKD is a congenital defect with a superimposed disease or injury, or whether it is a congenital disease that has been aggravated by service. The February 2017 VA examiner opined that PKD is a genetic disease. The Veteran subsequently submitted an opinion by a private medical treatment provider, Dr. C.S., noting a familial history of PKD, that it was present in service, citing intravenous pyelogram (IVP) findings and blood pressure readings, and that more likely than not the condition was progressing, which is consistent with the natural history of the disease. Moreover, Dr. C.S. cited recent medical records, which showed numerous bilateral cysts consistent with adult-onset autosomal dominant cystic kidney disease. See June 2017 private medical treatment record. Accordingly, the Board finds that the Veteran's PKD is a congenital disease. Dr. C.S. rendered a medical opinion with reasoned medical explanations and analysis. Dr. C.S. characterized the Veteran's PKD as a "disease" that has undergone progress (rather than a "defect," which is considered incapable of deteriorating or improving, see VAOPGCPREC 82-90), and also characterized it as "adult-onset autosomal dominant cystic kidney disease." Having so found, the next question for the Board is whether there is clear and unmistakable evidence that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). Here, Dr. C.S. opined that the progress of the Veteran's PKD had progressed as consistent with the natural history of the disease. Accordingly, the Board finds that there is clear and unmistakable evidence that the increase in the Veteran's PKD is due to its natural progression. In sum, service connection of a congenital disease requires aggravation clearly and unmistakably beyond the natural progress of the disease. Because the Board has found the Veteran's PKD to be a congenital disease without aggravation beyond the natural progress of the disease, service connection must be denied. REASONS FOR REMAND Entitlement to service connection for gout of the bilateral wrists, fingers and toes, as secondary to nephrolithiasis, is remanded. The Board notes that the Veteran has indicated that his gout condition impacts his wrists, fingers, and toes. See November 2016 lay statement; January 2017 correspondence; and April 2021 Board hearing. Thus, the Board has recharacterized the Veteran's claim more broadly to gout of the bilateral wrists, fingers and toes, in order to clarify the nature of the benefit sought and ensure complete consideration of the claim. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). Accordingly, the Board finds that the claim must be remanded to obtain an addendum medical opinion. The matter is REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate medical professional to determine the nature and etiology of the Veteran's gout. If the examiner determines that another VA examination is necessary to provide an informed opinion, such an examination should be scheduled. After reviewing the claims folder in its entirety, the examiner should address the following: a. Determine whether the Veteran's gout was proximately due to or the result of his service-connected nephrolithiasis. b. Determine whether the Veteran's gout was aggravated by his service-connected nephrolithiasis. A complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and must state whether there is additional evidence that would permit the necessary opinion to be made. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Minaya, 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.