Citation Nr: 22016871 Decision Date: 03/23/22 Archive Date: 03/23/22 DOCKET NO. 15-33 276 DATE: March 23, 2022 ORDER Entitlement to service connection for Wegener's granulomatosis is granted. Entitlement to service connection for an eye disability, diagnosed as right eye scleritis and bilateral subcapsular cataracts, as secondary to Wegener's granulomatosis, is granted. Entitlement to service connection for hypertension, as secondary to Wegener's granulomatosis, is granted. REMANDED Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as due to exposure to environmental hazards, or as secondary to Wegener's granulomatosis, is remanded. Entitlement to service connection for bilateral plantar fasciitis is remanded. Entitlement to service connection for a left knee disability, to include as secondary to Wegener's granulomatosis, is remanded. FINDINGS OF FACT 1. Resolving all reasonable doubt in his favor, the Veteran's Wegener's granulomatosis is causally or etiologically due to service. 2. The preponderance of evidence indicates the Veteran's right eye scleritis and bilateral subcapsular cataracts are proximately due to his service-connected Wegener's granulomatosis. 3. Resolving all reasonable doubt in his favor, the Veteran's hypertension is proximately due to his Wegener's granulomatosis. CONCLUSIONS OF LAW 1. The criteria for service connection for Wegener's granulomatosis are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for right eye scleritis and bilateral subcapsular cataracts, as secondary to Wegener's granulomatosis, are 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 hypertension, as secondary to Wegener's granulomatosis, are 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 had active service from July 1992 to November 1992, August 2005 to October 2005, and January 2007 to March 2007, with service in Southwest Asia. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a July 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran requested a hearing before the Board. The requested hearing was conducted in February 2018 by a Veterans Law Judge no longer employed by the Board. A transcript is associated with the claims file. A second hearing was conducted in November 2020 by the undersigned Veterans Law Judge. A transcript is associated with the claims file. In September 2021, the Veteran was mistakenly sent a hearing scheduling notification. This letter was sent in error, as the previously requested hearing was conducted in November 2020 and the Veteran did not subsequently request an additional hearing. Service Connection The Veteran seeks entitlement to service connection for Wegener's granulomatosis, an eye disability, and hypertension. In general, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection generally requires credible and competent evidence showing: (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. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); 38 C.F.R. § 3.303. Service connection may be granted on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a) and (b). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish entitlement to service connection on a secondary basis, there must be evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To do so, the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. See Masors v. Derwinski, 2 Vet. App. 181 (1992). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant). 1. Entitlement to service connection for Wegener's granulomatosis. The Veteran seeks entitlement to service connection for Wegener's granulomatosis. First, the Veteran has a diagnosis of Wegener's granulomatosis. See April 2018 letter from Dr. W. As such, Shedden element (1) is met. Regarding Shedden element (2), the Veteran contends that he was exposed to environmental hazards, including burn pits, while serving in Southwest Asia. The Veteran's military personnel records and service treatment records confirm that the Veteran was stationed in Southwest Asia. Service treatment records specifically document exposure to multiple hazards, including burn pits, pesticides, chemicals, and sand/dust. See, e.g., April 2007 Post-Deployment Health Assessment. Thus, the second element of service connection is met. As for Shedden element (3), nexus, the Board finds the evidence is at least in equipoise that his current diagnosis is causally or etiologically due to environmental exposures during service. The Board acknowledges a February 2012 VA opinion which negatively opines that the Veteran's Wegener's granulomatosis is not likely related to his time in service. The examiner stated that it is an immune mediated disorder; usual risk factors and possible initiating events are infectious, genetic, and environmental factors, like silica dust, mercury, and lead exposure. Importantly, however, the Board notes that the Veteran's exposure to airborne hazards and burn pit exposures, such as dust/sand and other particulate matter, has been conceded. A private medical opinion, dated April 2012, opines that the Veteran has no family history of autoimmune disorders and had an autoimmune trigger in that he was stationed at a base in close proximity to burn pits. The physician, Dr. W., noted that there are reports of toxins released into the air and carried for several miles that are linked to long term health problems. The physician opined it is as likely as not that the Veteran's autoimmune disease Wegener's granulomatosis is related to his exposures as a Gulf War Veteran to toxins released from the burn pits near his base. In December 2019, the Board requested an expert medical opinion from the Veterans' Health Administration (VHA). See 38 C.F.R. § 20.901. A VHA opinion was received in February 2020. The specialist opined that it is at least as likely as not that the Veteran's Wegener's disease was caused by his time in service, to include exposure to environmental hazards, as multiple studies link the disease to silica dust. The Board finds the positive private and VHA opinions persuasive. The Board finds no adequate basis to reject the evidence of record that is favorable to the Veteran, based on a lack of credibility or probative value. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Evans v. West, 12 Vet. App. 22, 26 (1998). Under the benefit of the doubt rule, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993); see also Massey v. Brown, 7 Vet. App. 204, 206-207 (1994). Given the evidence of record, the Board resolves doubt in the Veteran's favor and finds that the evidence supports the establishment of service connection for Wegener's granulomatosis. The Veteran has a current diagnosis, documented exposures to environmental hazards during service, and medical opinions that relate his current diagnosis to his time in service. In light of the discussion above, while the evidence is not unequivocal, it has nonetheless placed the record in relative equipoise. As such, the Veteran's service connection claim for Wegener's granulomatosis is granted. 2. Entitlement to service connection for an eye disability (claimed as scleritis). The Veteran seeks entitlement to service connection for an eye disability, claimed as scleritis. He asserts he has an eye disability as secondary to Wegener's granulomatosis. Because the Board is granting this claim on a secondary basis based on causality, it will not discuss direct service connection in this section. The Veteran has current diagnoses of right eye scleritis and bilateral subcapsular cataracts. See February 2012 VA examination. As such, element (1) set forth under Allen, current disability, has been satisfied. As a result of this Board decision, the Veteran has been granted service connection for Wegener's granulomatosis. In a February 2012 opinion, a VA examiner opined the Veteran's right eye scleritis was at least as likely as not due to Wegener's disease, explaining that Wegener's disease affects the eyes. The February 2012 VA examiner also opined that the Veteran's bilateral posterior subcapsular cataracts are proximately due to the Veteran's Wegener's disease, as the cataracts are a result of steroids that were used to treat Wegener's disease. There are no medical opinions to the contrary of record. The Veteran has current diagnoses and a medical opinion relating his disorders to a service-connected disability. As such, service connection for scleritis of the right eye and for bilateral subcapsular cataracts are granted, as secondary to service-connected Wegener's granulomatosis. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to service connection for hypertension. The Veteran seeks entitlement to service connection for hypertension. Because the Board is granting this claim on a secondary basis based on causality, it will not discuss direct service connection in this section. The Veteran has a current diagnosis of hypertension. See February 2012 VA examination. As such, element (1) set forth under Allen, current disability, has been satisfied. As a result of this Board decision, the Veteran has been granted service connection for Wegener's granulomatosis. In a February 2012 opinion, a VA examiner negatively opined regarding direct service connection, however, an opinion on secondary service connection was not provided. The February 2020 VHA specialist opined that it was not at least as likely as not that the Veteran's hypertension was caused or aggravated by his Wegener's disease. The specialist stated that medical records indicate the Veteran had hypertension as early as September 2008 and the Veteran was not diagnosed with Wegener's until 2011. The specialist explained that symptoms suggestive of Wegener's appear to have come on in the first few months of 2011 (arthritis, scleritis, etc.), therefore, it is extremely unlikely that Wegener's would have persisted for over a year with renal involvement sufficient to cause hypertension without an earlier diagnosis. Importantly, however, the Board notes that the September 2008 treatment record referred to by the February 2020 VHA specialist indicates that the Veteran was assessed with borderline hypertension and was not diagnosed with hypertension, at that time. Furthermore, medical records indicate that the Veteran began experiencing symptoms from Wegener's disease as early as a few months after separation from service, which would place an onset of symptoms as early as 2007, not 2011. See, e.g., March 2011 private treatment record; July 2018 opinion from Dr. L. In February 2021, the Veteran's private physician, Dr. L., opined that the Veteran's hypertension was a complication of his Wegener's disease, explaining that he was diagnosed with hypertension after his diagnosis of Wegener's disease and his hypertension was likely due to kidney injury as a result of treatment with prednisone. The Board acknowledges that, unfortunately, the physician did not discuss the Veteran's history of borderline hypertension, prior to his Wegener's diagnosis. As both medical opinions have deficiencies, the Board finds that the evidence is in at least equipoise as to whether the Veteran's hypertension is secondary to his Wegener's granulomatosis. As such, service connection for hypertension is granted, as secondary to service-connected Wegener's granulomatosis. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). RUEASONS FOR REMAND 4. Entitlement to service connection for GERD. The Veteran seeks entitlement to service connection for GERD. The Veteran has asserted multiple theories of entitlement, to include both direct and secondary as based on aggravation. First, the Board notes that the Veteran has a current diagnosis of GERD. See, e.g., February 2012 VA examination. The Veteran's May 1992 enlistment examination did not note any GERD diagnosis or symptoms. Service treatment and personnel records confirm exposure to a multitude of substances, including burn pits, pesticides, and various chemicals. The Veteran testified in November 2020 that he began experiencing symptoms of GERD during service, such as chronic heartburn, in 2006 while on deployment to Iraq, and that he self-medicated using over-the-counter treatment at that time. A September 2008 VA treatment note, however, indicates the Veteran reported experiencing heartburn since high school. The Veteran also submitted a private medical opinion, dated February 2021, in which the physician, Dr. L., opined that the Veteran's GERD existed prior to his Wegener's granulomatosis, but that it likely became worse as a result of prednisone, used to treat his Wegener's disease, causing laxity of the lower esophageal sphincter. A VA medical opinion for direct service connection was obtained in February 2012, however, the VA examiner provided a conclusory statement that the Veteran's GERD was not likely due to service, simply noting that there was no documentation of the disorder during service or immediately after he left active service. A February 2020 VHA specialist opined that the Veteran's GERD was not caused by his Wegener's granulomatosis, noting the September 2008 VA treatment note reporting GERD symptoms since high school. The VHA specialist also opined that it was difficult to make a case that the Veteran's Wegener's granulomatosis was responsible for aggravating his GERD as the Veteran was already gaining weight prior to the onset of his Wegener's and obesity could explain a worsening of GERD. The Board finds an addendum opinion must be obtained that utilizes the correct standard when opining whether a disorder pre-existed service. 5. Entitlement to service connection for bilateral plantar fasciitis. The Veteran seeks entitlement to service connection for bilateral plantar fasciitis. The Veteran asserts that upon entry to service, he was using orthotics for his feet due to bilateral pes planus, but that at the time, he was not experiencing pain. The Veteran asserts that walking flight lines, standing on concrete, and climbing ladders for aircraft maintenance, aggravated his feet, causing his bilateral plantar fasciitis. The Veteran's May 1992 enlistment examination did not note the use of orthotics or any foot abnormalities. The Veteran has a post-service diagnosis of bilateral plantar fasciitis. See February 2012 VA examination. The Board notes the February 2012 VA examiner opined that the Veteran's bilateral plantar fasciitis was less likely than not due to service because there was no documentation of the disorder during service or immediately after discharge. A remand is necessary to obtain an addendum opinion that addresses whether the Veteran's claimed bilateral foot disability pre-existed service and was aggravated therein. The opinion should address the Veteran's asserted theory of entitlement. 6. Entitlement to service connection for a left knee disability, to include as secondary to service-connected Wegener's granulomatosis. The Veteran seeks entitlement to service connection for a left knee disability. He asserts he injured his left knee during service while in Iraq in 2006 and sought treatment at that time. The Veteran has a post-service diagnosis of a grade 2 tear of the posterior horn medial meniscus of the left knee. The Board notes that service treatment records document a right knee injury during service in early 2007 in Iraq, but not a left knee injury. See, e.g., February 2007, March 2007 service treatment records; March 2007 Line of Duty Determination. There is no documentation of a left knee injury. The Veteran asserts, however, that he experienced left knee pain during service as a result of walking on uneven terrain as well as twisting it during service. The Veteran argues that he possibly partially tore his ligament during service, although not diagnosed as the time, which led to the post-service tear. Additionally, a February 2009 treatment note indicates the Veteran complained of aches and pains in his joints, to include his knees. A July 2018 private medical opinion states that the Veteran's Wegener's granulomatosis first manifested as sinus congestion and nose bleeding, which was then followed by characteristic involvement of the joints. On remand, a VA opinion should be obtained that addresses the Veteran's asserted theories. A VA opinion should also be obtained regarding whether the Veteran's claimed left knee disability is secondary to his service-connected Wegener's granulomatosis. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all updated treatment records. 2. Obtain an addendum opinion for the Veteran's GERD. No additional examination is necessary, unless deemed necessary by the examiner. Based on a review of the claims file, the examiner should opine as to: a) Is there clear and unmistakable (undebatable) evidence that the Veteran's GERD pre-existed service? b) If the Veteran's GERD clearly and unmistakably pre-existed service, the examiner should determine whether it is clear and unmistakable that his GERD was not aggravated beyond the natural progress of the disorder by his time in service. c) If the Veteran's GERD did not clearly and unmistakably pre-exist service, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., 50 percent or greater probability) that any current GERD is causally or etiologically due to his time in service, to include conceded exposure to environmental hazards, OR is proximately due to OR aggravated (beyond a natural progression) by his service-connected Wegener's granulomatosis. *The examiner should consider and discuss the following: i) GERD was not noted on the Veteran's May 1992 enlistment examination; ii) a September 2008 VA treatment note indicating the Veteran reported experiencing heartburn since high school; iii) the Veteran's testimony in November 2020 that he began experiencing symptoms of GERD during service, such as chronic heartburn, in 2006, while on deployment to Iraq, and that he self-medicated with over-the-counter treatment at that time; iv) the February 2021 private medical opinion that the Veteran's GERD existed prior to his Wegener's granulomatosis, but that it likely became worse as a result of prednisone, used to treat his Wegener's disease, and caused laxity of the lower esophageal sphincter. v) the February 2020 VHA specialist's opinion that the Veteran was already gaining weight prior to the onset of his Wegener's and obesity, rather than his Wegener's disease, could explain a worsening of GERD. All opinions should be supported by a clear rationale and a discussion of the facts and medical principles involved would be of considerable assistance. 3. Obtain an addendum opinion for the Veteran's bilateral plantar fasciitis. No additional examination is necessary, unless deemed necessary by the examiner. Based on a review of the claims file, the examiner should opine as to: a) Is there clear and unmistakable (undebatable) evidence that the Veteran's bilateral plantar fasciitis pre-existed service? b) If the Veteran's bilateral plantar fasciitis clearly and unmistakably pre-existed service, the examiner should determine whether it is clear and unmistakable that his bilateral plantar fasciitis was not aggravated beyond the natural progress of the disorder by his time in service. c) If the Veteran's bilateral plantar fasciitis did not clearly and unmistakably pre-exist service, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., 50 percent or greater probability) that any current bilateral plantar fasciitis is causally or etiologically due to his time in service. *The examiner should consider and discuss the following: i) bilateral plantar fasciitis was not noted on the Veteran's May 1992 enlistment examination; ii) the Veteran's assertions that he wore orthotics prior to service for bilateral pes planus, but that he did not experience pain prior to service; iii) the Veteran's asserted theory that walking flight lines, standing on concrete, and climbing ladders for aircraft maintenance, aggravated his feet, causing his bilateral plantar fasciitis. All opinions should be supported by a clear rationale and a discussion of the facts and medical principles involved would be of considerable assistance. 4. Obtain an addendum opinion for the Veteran's left knee disability. No additional examination is necessary, unless deemed necessary by the examiner. Based on a review of the claims file, the examiner should opine as to: a) whether it is at least as likely as not (i.e., 50 percent or greater probability) that the Veteran's left knee disorder is causally or etiologically due to his time in service, OR b) whether it is at least as likely as not that the Veteran's left knee disorder is proximately due to OR aggravated (beyond a natural progression) by his service-connected Wegener's granulomatosis. *The examiner should consider and discuss the following: i) the in-service documented injury to the right knee; ii) the Veteran's assertions that he experienced left knee pain during service as a result of walking on uneven terrain as well as twisting it during service; iii) the Veteran's argument that he possibly partially tore his ligament during service, although not diagnosed at the time, which led to the post-service tear; iv) a February 2009 treatment note indicating the Veteran complained of aches and pains in his joints, to include his knees; v) a July 2018 private medical opinion that states that the Veteran's Wegener's granulomatosis first manifested as sinus congestion and nose bleeding, which was then followed by characteristic involvement of the joints. All opinions should be supported by a clear rationale and a discussion of the facts and medical principles involved would be of considerable assistance. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Andersen, 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.