Citation Nr: 22018186 Decision Date: 03/28/22 Archive Date: 03/28/22 DOCKET NO. 19-01 828 DATE: March 28, 2022 ORDER Service connection for Barrett's esophagus, to include as secondary to obstructive sleep apnea, is granted. FINDING OF FACT The Veteran's current Barrett's esophagus is directly related to service and his service-connected obstructive sleep apnea. CONCLUSION OF LAW The criteria for service connection for Barrett's esophagus, to include as secondary to obstructive sleep apnea, are met. 38 U.S.C. §§ 1101, 1110, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1967 to April 1970, including combat service in Vietnam. This appeal is before the Board of Veterans' Appeals (Board) from an August 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. In November 2021, the Veteran and his spouse testified during a Board hearing before the undersigned Veterans Law Judge via videoconference. A transcript is included in the claims file. The Veteran elected to proceed at the hearing without the presence of his representative. Entitlement to service connection for Barrett's esophagus, to include as secondary to obstructive sleep apnea The Veteran claims service connection for Barrett's esophagus. 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(a). Service connection requires: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). In the case of a veteran who engaged in combat with the enemy in a period of war, lay evidence of in-service incurrence or aggravation of a disease or injury shall be accepted if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the lack of official record of such incurrence or aggravation. The incurrence or aggravation may be rebutted by clear and convincing evidence to the contrary. See 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d); Libertine v. Brown, 9 Vet. App. 521, 524 (1996); Collette v. Brown, 82 F.3d 389, 392-94 (Fed. Cir. 1996). The standard used to determine whether a veteran engaged in combat with the enemy is reasonable doubt, which is to be resolved in a veteran's favor. See VAOPGCPREC 12-99. The provisions of 38 U.S.C. § 1154(b), however, can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to a current disorder. See Libertine, 9 Vet. App. at 522-23. The provisions of 38 U.S.C. § 1154(b) do not establish service connection for a combat veteran; it aids him by relaxing the adjudicative evidentiary requirements for determining what happened in service. Clyburn v. West, 12 Vet. App. 296, 303 (1999). Service treatment records do not reflect any symptoms of or treatment for Barrett's esophagus. No such abnormality was noted at the Veteran's April 1970 separation examination. In a July 2016 statement, the Veteran reported that he had a bad problem with acid reflux since the early 1980s. He stated that he researched the problem and found a direct link to sleep apnea. His acid reflux had since developed into Barrett's esophagus. He reiterated these contentions in a statement associated with his October 2016 notice of disagreement. At a June 2018 RO hearing, the Veteran reported that his surgeon told him that his Barrett's esophagus was directly caused by his sleep apnea. The Veteran underwent a VA examination in October 2018. He was diagnosed with Barrett's esophagus confirmed by an esophagogastroduodenoscopy (EGD) in March 2016. The examiner opined that the Veteran's disability was less likely than not caused or aggravated by his sleep apnea. This opinion was based on the rationale that obstructive sleep apnea is not considered to be a significant risk factor for or known aggravator of Barrett's esophagus, which is caused by reflux. The examiner, a physician assistant, added an extraneous observation that it was "interesting to note" that service connection for sleep apnea was granted on appeal without any opinion from a sleep medicine specialist. At his November 2021 hearing, the Veteran stated that his reflux began in service, but he did not seek treatment while in Vietnam. He explained that seeking treatment for such a disability while serving in Vietnam would be frowned upon, and he was discharged about two weeks after his deployment ended. His spouse confirmed that he did not have acid reflux until he came back from Vietnam. He stated that shortly after he was diagnosed with sleep apnea, his acid reflux worsened and was placed on medication. He underwent an EGD to see if he had an ulcer, and he was told that he had Barrett's esophagus. The surgeon then asked if he had sleep apnea and told him that sleep apnea was rumored to cause acid reflux, which in turn caused his Barrett's esophagus. He further stated that once he got his sleep apnea under control, his Barrett's symptoms likewise calmed down. He stated that the surgeon who told him about the relationship between sleep apnea and acid reflux had since retired and was unable to provide a nexus opinion. (Continued on the next page) The Board finds that the evidence is at least in equipoise as to whether the Veteran's Barrett's esophagus is directly related to service and his service-connected obstructive sleep apnea. The October 2018 VA examiner's opinion unhelpfully explained that Barrett's esophagus is caused not by sleep apnea but by acid reflux. The question, however, is what caused the acid reflux, which the Veteran claims arose in service and was aggravated by his sleep apnea. The examiner cited no medical literature to support the assertion that sleep apnea is not a known risk factor or aggravator for Barrett's esophagus. No opinion was offered as to direct service connection. The probative value of the examiner's opinion is further reduced by the editorial comments suggesting a belief that the Veteran was improperly granted service connection for sleep apnea without the opinion of a sleep specialist. Fortunately, remand is not necessary to obtain an opinion from a gastroenterology specialist. The Veteran credibly reported acid reflux arising in service, corroborated by testimony from his wife. His failure to seek treatment on active duty was consistent with the circumstances of his combat service. There is no reason to doubt the VA examiner's statement that his acid reflux in turn caused his Barrett's esophagus. For these reasons, the Board finds that the evidence is at least in equipoise as to whether the Veteran's Barrett's esophagus is directly related to service and his service-connected obstructive sleep apnea. Service connection is therefore granted. Rebecca N. Poulson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Gallagher, 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.