Citation Nr: 22016403 Decision Date: 03/22/22 Archive Date: 03/22/22 DOCKET NO. 17-24 281 DATE: March 22, 2022 ORDER Entitlement to service connection for Crohn's disease, to include as secondary to service-connected diabetes mellitus, is denied. Entitlement to service connection for clear cell renal carcinoma, to include as secondary to diabetes mellitus, is denied. REMANDED Entitlement to service connection for a bowel disorder, to include irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD), is remanded. FINDINGS OF FACT 1. The persuasive weight of the evidence is against finding the Veteran's Crohn's disease is due to service, to include as due to herbicide agent exposure or secondary to his service-connected diabetes. 2. The persuasive weight of the evidence is against finding the Veteran's clear cell renal carcinoma is due to his service, to include as due to herbicide agent exposure or secondary to his service-connected diabetes. CONCLUSIONS OF LAW 1. The criteria for service connection for Crohn's disease, to include as secondary to service-connected diabetes mellitus, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for clear cell renal carcinoma, to include as secondary to diabetes mellitus, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Air Force from November 1967 to November 1971. These matters come before the Board of Veterans' Appeals (Board) on appeal of an October 2016 rating decision concerning IBS and Crohn's disease, and an August 2017 rating decision concerning a kidney condition, both from a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge at an August 2021 videoconference hearing, and a transcript of this hearing is associated with the claims file. These matters were previously before the Board in November 2021, at which time they were remanded in order to obtain VA examinations. Service Connection Service connection will be granted if the evidence in the record demonstrates that a current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) an in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Secondary service connection is warranted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Briefly, the threshold legal requirements for a successful secondary service connection claim are: (1) Evidence of a current disability for which secondary service connection is sought; (2) a disability for which service connection has been established; and (3) competent evidence of a nexus between the two. The Veteran is competent to report symptoms experienced. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, he is not considered competent to medically attribute such symptoms to any particular disability because such is a complicated medical issue that requires medical knowledge and expertise the Veteran has not been shown to possess. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Buchanan v. Nicholson, 451 F. 3d 1331, 1336-37 (2006). The Board notes the Veteran had in-country service in the Republic of Vietnam during the Vietnam Era, and therefore is presumed to have been exposed to herbicide agents during service. 1. Entitlement to service connection for Crohn's disease, to include as secondary to service-connected diabetes mellitus, is denied. The Veteran contends that his Crohn's disease is either due to his in-service herbicide exposure or is secondary to his service-connected diabetes. The Veteran's service treatment records are silent with respect to a diagnosis of Crohn's disease, as well as for other gastrointestinal symptoms and conditions. The Veteran's VA treatment records show a current diagnosis of Crohn's disease. The Veteran was afforded a records review examination in January 2022, as well as an addendum opinion by the same examiner in January 2022. In the records review examination, the examiner noted the Veteran has a diagnosis of Crohn's disease. The examiner found that Crohn's was not listed under 38 C.F.R. § 3.309(e) as a disease afforded presumptive service connection due to herbicide agent exposure. Additionally, in the January 2022 addendum opinion, the examiner stated that the current medical literature does not support a causal relationship between herbicide agent exposure and Crohn's. Furthermore, the medical literature does not support a causal relationship between Crohn's and diabetes, nor did it support the idea that diabetes would aggravate Crohn's. The Veteran testified during the August 2021 hearing that he believes there was a connection between his Crohn's and diabetes, as well as a relationship between his Crohn's and his herbicide agent exposure. However, his doctors were hesitant to provide any nexus opinions in writing. He further stated that he believes that VA has additional information showing a connection between Crohn's and diabetes, as well as information on this condition and herbicide agent exposure. The Board finds that the persuasive weight of the evidence is against finding that the Veteran's Crohn's disease is either due to his service or secondary to his service-connected diabetes. The Board finds the January 2022 examination and addendum opinion to be of great probative value. The examiner clearly explained how the medical literature does not support a causal link between herbicide exposure and Crohn's. Additionally, the examiner explained that the scientific evidence does not support a causal link between Crohn's and diabetes, nor does it support the idea that diabetes can aggravate Crohn's. The Board understands that the Veteran believes his Crohn's is related to either his herbicide agent exposure or his service-connected diabetes. The Veteran is competent to describe events and symptoms he has experienced, as well as relay information his physicians have told him. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, he is not considered competent to medically attribute such symptoms to any particular disability because such is a complicated medical issue that requires medical knowledge and expertise the Veteran has not been shown to possess. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Buchanan v. Nicholson, 451 F. 3d 1331, 1336-37 (2006). Accordingly, the Board finds that the Veteran's Crohn's disease is less likely than not related to his service or to his service-connected diabetes. As the persuasive weight of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the claim for entitlement to service connection for Crohn's disease, on both a direct and a secondary basis, must be denied. 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). 2. Entitlement to service connection for clear cell renal carcinoma, to include as secondary to diabetes mellitus, is denied. The Veteran contends that his clear cell renal carcinoma is due to either his exposure to herbicide agents during service or is otherwise secondary to his service-connected diabetes. The Veteran's STRs are silent regarding any kidney conditions or related symptoms during service. His VA treatment records do note a diagnosis of clear cell renal carcinoma. The Veteran was afforded a VA examination in August 2017 and a records review examination in January 2022, with a January 2022 addendum opinion by the same examiner. The Board previously found the August 2017 examination to be inadequate. In the January 2022 examination, the examiner noted the Veteran had a diagnosis of clear cell renal carcinoma. The examiner noted that clear cell renal carcinoma was not among the conditions listed under 38 C.F.R. § 3.309(e) for presumptive service connection due to herbicide agent exposure. Additionally, the examiner noted the current medical literature does not support a causal relationship between clear cell renal carcinoma and herbicide agent exposure. Furthermore, the examiner explained that the medical literature does not support a causal relationship between diabetes and clear cell renal carcinoma. Furthermore, the examiner noted that there is no scientific evidence that diabetes can aggravate clear cell carcinoma. In his August 2021 hearing testimony, the Veteran stated that he believes his clear cell renal carcinoma is related to either his herbicide agent exposure or his diabetes, although no physicians have been willing to provide a positive nexus opinion. He also explained that he had no family history of kidney conditions, including kidney cancers. This is primarily why he believes his clear cell renal carcinoma is related to his service. After reviewing the record, the Board finds the persuasive weight of the evidence is against service connection for clear cell renal carcinoma. The Board finds the January 2022 examination and addendum opinion to be of great probative value. The examiner explained how the medical literature does not support a causal link between herbicide exposure and clear cell renal carcinoma. Additionally, the examiner explained that the scientific evidence does not support a causal link between clear cell renal carcinoma and diabetes, nor does it support the idea that diabetes can aggravate clear cell renal carcinoma. The Board understands that the Veteran believes his clear cell renal carcinoma is related to either his herbicide agent exposure or his service-connected diabetes. The Veteran is competent to describe events and symptoms he has experienced, as well as relay information his physicians have told him. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, he is not considered competent to medically attribute such symptoms to any particular disability because such is a complicated medical issue that requires medical knowledge and expertise the Veteran has not been shown to possess. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Buchanan v. Nicholson, 451 F. 3d 1331, 1336-37 (2006). Accordingly, the Board finds that the Veteran's clear cell renal carcinoma is less likely than not related to his service or to his service-connected diabetes. As the persuasive weight of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the claim for entitlement to service connection for clear cell renal carcinoma must be denied. 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). REASONS FOR REMAND Entitlement to service connection for a bowel disorder, to include irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD), is remanded. The Veteran contends that he has a bowel disorder that is either due to his in-service herbicide agent exposure or is proximately due to or aggravated by his service-connected diabetes. The Veteran's service treatment records are silent with respect to diagnoses of IBS, as well as for other gastrointestinal symptoms and conditions. The Veteran's post-service treatment records include a mention of IBS; however. the records do not indicate the Veteran has an official diagnosis of IBS. His records do show a diagnosis of IBD. The Veteran was afforded a records review examination in January 2022, as well as an addendum opinion by the same examiner in January 2022. In the records review examination, the examiner noted the Veteran did not have a confirmed diagnosis of IBS. The examiner found that IBS was not listed under 38 C.F.R. § 3.309(e) as a disease afforded presumptive service connection due to herbicide agent exposure. Additionally, in the January 2022 addendum opinion, the examiner stated that the current medical literature does not support a causal relationship between herbicide agent exposure and IBS. The examiner did note that diabetes can cause nerve damage in the large intestine that can either lead to or aggravate symptoms of IBS. However, because the Veteran does not have a confirmed diagnosis of IBS, the examiner found that this condition was less likely than not secondary to the Veteran's diabetes. The Veteran testified during the August 2021 hearing that he has a diagnosis of IBS. Additionally, he stated that he believes there was a connection between his IBS and diabetes, as well as a relationship between IBS and his herbicide agent exposure. However, his doctors were hesitant to provide any nexus opinions in writing. He further believes that VA has additional information showing a connection between his IBS and diabetes, as well as information on these conditions and herbicide agent exposure. After reviewing the evidence of record, the Board finds the January 2022 examinations to be inadequate. The Board recognizes that the Veteran believes he has IBS; however, his medical records indicate that he actually has a diagnosis of IBD, which is a separate and distinct medical condition, although it is commonly confused with IBS. While the examiner addressed the Veteran's claimed IBS, they did not consider the diagnosis of IBD. Because of this confusion over the Veteran's diagnosed bowel disability, the Board finds that an addendum opinion is necessary in order to determine if the Veteran has IBS, IBD, or both conditions, and whether any of these conditions are related to either herbicide agent exposure or are secondary to his service-connected diabetes. Accordingly, this matter is REMANDED for the following: 1. Obtain an addendum opinion from a qualified examiner addressing the nature and etiology of the Veteran's gastrointestinal conditions. The examiner is asked to address the following: (a.) Determine whether the Veteran has a diagnosis of irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), or both. (b.) For each diagnosis found to be present, determine whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's IBS and/or IBD is related to service, to include in-service herbicide exposure. (c.) For each diagnosis found to be present, determine whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's IBS and/or IBD is proximately due to his service-connected diabetes. (d.) For each diagnosis found to be present, determine whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's IBS and/or IBD is aggravated by his service-connected diabetes. The examiner is to note that with respect to herbicide exposure, if the Veteran's condition is not eligible for presumptive service connection under 38 C.F.R. § 3.309(e), they must still address entitlement to service connection on a direct basis. Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Gabrielle Ongies, 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.