Citation Nr: 22014465 Decision Date: 03/14/22 Archive Date: 03/14/22 DOCKET NO. 15-03 596A DATE: March 14, 2022 REMANDED Entitlement to service connection for bilateral ocular histoplasmosis is remanded. Entitlement to service connection for scarring of the lungs, due to bilateral ocular histoplasmosis, is remanded. ORDER Entitlement to service connection for amputation of the left leg below the knee, to include as secondary to service-connected disabilities is denied. FINDING OF FACT The Veteran's left leg amputation below the knee was not secondary to (caused or aggravated by) service-connected coronary artery disease and is not otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for amputation of the left leg below the knee due to service or secondary to coronary artery disease are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from March 1973 to November 1975. This matter comes before the Board of Veterans' Appeals (Board) from the rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran appeared at a December 2017 hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. Sadly, the Veteran passed away in March 2021 and the Veteran's surviving spouse has been substituted as the Appellant. 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, 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). The question for the Board is whether the Veteran had a current disability that began during service or was at least as likely as not related to an in-service injury, event, or disease. Entitlement to service connection for amputation of the left leg below the knee, to include as secondary to service-connected disabilities Prior to his death, the Veteran contended that his left leg disability (amputation of the left leg below the knee) was secondary to his service-connected coronary artery disease. The Veteran's service treatment records do not contain any references to left leg problems. He also did not link the left leg problem directly to service in his testimony. Because the Veteran had not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board's adjudication will consider only entitlement to secondary service connection. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran had a current disability that was proximately due to or the result of, or was aggravated beyond its natural progress by service-connected disability coronary artery disease. The Board concludes that, while the Veteran had a current disability, the evidence of record persuasively weighs against finding that the Veteran's amputation of the left leg below the knee was proximately due to or the result of, or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The January 2022 VA examiner opined that the Veteran's left leg amputation disability was instead more likely due to peripheral vascular disease and not the Veteran's coronary artery disease. The rationale was that the Veteran was diagnosed with peripheral vascular disease as early as 1991/1992, which progressed resulting in a left leg below the knee amputation. The examiner explained that pathophysiological, a left leg below the knee amputation and coronary artery disease are separate and distinct conditions. Specifically, the Veteran's below the knee amputation was due to peripheral vascular disease, which is a condition of the peripheral vascular system, whereas coronary artery disease is a condition of the heart due to disease in the coronary arteries. Therefore, the examiner opined that the Veteran's left leg below the knee amputation condition was less likely caused or aggravated by his service connected coronary artery disease. The Board acknowledges that the Veteran, prior to his death, and his surviving spouse, believe the Veteran's amputation was proximately due to or the result of a service-connected disability. However, the Veteran and his surviving spouse in this case are not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body. Therefore, it is outside the competence of the Veteran and his surviving spouse in this case because the record does not show that they have the skills or medical training 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 medical opinion of record. Therefore, entitlement to service connection for amputation of the left leg below the knee, secondary to the Veteran's service connected coronary artery disease, is not warranted. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the persuasive weight of the evidence is against the Appellant's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b). REASONS FOR REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. 1. Entitlement to service connection for bilateral ocular histoplasmosis is remanded. 2. Entitlement to service connection for scarring of the lungs, due to bilateral ocular histoplasmosis, is remanded. Pursuant to the Board's November 2019 remand, an August 2021 VA opinion was obtained. The examiner stated that histoplasmosis was not noted or documented during the Veteran's military service. Therefore, the examiner opined that it is less likely than not the Veteran's bilateral ocular histoplasmosis was incurred in or due to military service. However, the Board notes that a VA examiner must offer a full rationale for all opinions given and should not rely solely on the absence of evidence of in-service treatment or injury in the Veteran's service treatment records as a basis for any given opinion. The examiner also stated that the Veteran's ocular histoplasmosis did not appear until significantly after military service. However, the examiner went on to say that histoplasmosis is a disease from breathing in infected airborne spores into your lungs. The examiner stated that histoplasmosis infection is often so mild that it produces no clear symptoms and presumed ocular histoplasmosis syndrome (POHS) often has no symptoms in its early stages and "you can often have POHS without knowing it." Additionally, the examiner stated that complications can arise "years or even decades later." Furthermore, the Board notes that in its November 2019 remand, it specifically directed the VA examiners to consider the Veteran's contention that he contracted his eye condition from the Mississippi river valley region when he was stationed in Louisiana during service. The examiner does not appear to consider this contention. Therefore, the Board finds that an addendum opinion must be obtained that provides an adequate opinion and rationale regarding whether or not the Veteran's bilateral ocular histoplasmosis was related to his military service. Specifically, the examiner must consider the Veteran's contentions regarding his potential exposure to histoplasmosis fungus while stationed in Louisiana, not rely solely on the absence of evidence of in-service treatment or injury, and consider the August 2021 examiner's statements that ocular histoplasmosis can arise decades later. Additionally, the Board notes that the April 2021 VA opinion obtained states that the Veteran's scarring of the lungs is proximately due to the Veteran's bilateral eye histoplasmosis. Therefore, the resolution of the claim for service connection for histoplasmosis in the bilateral eyes might be determinative of the lung scarring claim on a secondary service connection basis, the issues are inextricably intertwined, and the lung scarring issue must also be remanded. See Henderson v. West, 12 Vet. App. 11, 20 (1998); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Obtain an addendum opinion by an appropriate clinician to determine the nature and etiology of the Veteran's bilateral ocular histoplasmosis. The examiner must opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's bilateral ocular histoplasmosis is related to an in-service injury, event, or disease. The examiner must consider the Veteran's contentions regarding his potential exposure to histoplasmosis fungus while stationed in Louisiana (as histoplasmosis is most commonly found in the Mississippi river valley region), not rely solely on the absence of evidence of in-service treatment or injury, and consider the August 2021 examiner's statements that ocular histoplasmosis can arise decades later. All opinions provided must be thoroughly explained and an adequate rationale for any conclusions reached must be provided. The examiner should not rely solely on the absence of evidence of in-service treatment or injury in the Veteran's service treatment records as a basis for any given opinion. If any requested opinion cannot be provided without resort to speculation, the medical professional should state and explain why an opinion cannot be provided without resort to speculation. 2. Following completion of the above, and a review of any additional evidence received, the RO should also undertake any other development it deems to be necessary, to include, if warranted, an addendum medical opinion which considers any newly received evidence. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Mountford, 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.