Citation Nr: 25005178 Decision Date: 04/16/25 Archive Date: 04/16/25 DOCKET NO. 15-21 587 DATE: April 16, 2025 ORDER Entitlement to service connection for diverticulosis is granted. REMANDED Entitlement to a staged initial rating higher than 10 percent for left knee osteoarthritis prior to January 31, 2023, and higher than 20 percent, thereafter, is remanded. Entitlement to a staged initial rating higher than 10 percent for right knee osteoarthritis prior to January 31, 2023, and higher than 30 percent, thereafter, is remanded. Entitlement to service connection for gastroduodenitis is remanded. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, the Veteran's diverticulosis began during active service. CONCLUSION OF LAW The criteria for service connection for diverticulosis are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from March 1973 to March 1985. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 2012 rating decision. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a hearing in September 2018. A transcript of that hearing is of record. An April 2023 rating decision a 30 percent rating for the right knee and a 20 percent rating for the left knee, both effective January 31, 2023. These matters have been remanded several times, most recently in May 2024. 1. Entitlement to service connection for diverticulosis The Veteran contends that his diverticulosis was caused by service, to include exposure to chemicals. Resolving doubt in the Veteran's favor, the Board finds that the evidence is at least in approximate balance as to whether the Veteran's diverticulosis was incurred in service. 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). A December 2021 VA examination diagnosed the Veteran with diverticulosis, noting that the Veteran had a barium enema study that showed mild diverticulosis in 1999, and that the Veteran notes having abdominal pain and rectal bleeding at that time. Although the Veteran was not diagnosed with diverticulosis in service, the Veteran's service treatment records (STRs) from September 1983 do note blood in the Veteran's stool intermittently over the course of six months. There are several opinions finding that diverticulosis is not caused by chemical exposure. However, they do not adequately address whether the rectal bleeding that the Veteran experienced in service is evidence of diverticulosis that was not diagnosed until after service. The Board finds that remanding again for additional development on the question of nexus is not needed. The development of evidence in connection with claims for service connection will be accomplished when deemed necessary. 38 C.F.R. § 3.304(c). In this case, in Board deems it unnecessary to continue to remand the claim. Following service, in March 1998, the Veteran sought treatment from a VA medical center for rectal bleeding that was noted could be internal hemorrhoids or diverticulosis. In May 2006, a VA treatment note states that the Veteran has had repeated spells of rectal bleeding over the past 20 years, and multiple EGD and colonoscopy that were all benign except for an internal hemorrhoid that was ligated but did not stop bleeding and air contrast barium enema (BaE) that showed diverticulosis coli, which is likely the cause of the bleeding. The Board notes that repeated spells of rectal bleeding for 20 years prior to 2006 would stretch back to approximately 1983, when the Veteran's STRs indicate that the Veteran experienced intermittent rectal bleeding. Resolving doubt in the Veteran's favor, the Board finds that the May 2006 VA treatment note finding that diverticulosis is the likely cause of the intermittent rectal bleeding that the Veteran has been experiencing since service is essentially an opinion finding that it is at least as likely as not that the Veteran's diverticulosis had its onset during service. For the foregoing reasons, the Board finds the evidence to be at least in approximate balance as to whether the Veteran's diverticulosis had its onset during service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for diverticulosis is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776, 782 (Fed. Cir. 2021). REASONS FOR REMAND 1. Entitlement to a staged initial rating higher than 10 percent for left knee osteoarthritis prior to January 31, 2023, and 20 percent, thereafter, is remanded. 2. Entitlement to a staged initial rating higher than 10 percent for right knee osteoarthritis prior to January 31, 2023, and 30 percent, thereafter, is remanded. The January 2023 VA examination notes that the treatment for the Veteran's bilateral knee disability is steroid and Synvisc injections. When the rating criteria do not contemplate the ameliorative effects of medication, such effects must be discounted when evaluating the severity of a service-connected condition. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). The requirement to discount the ameliorative effects of medication applies when evaluating the severity of musculoskeletal disabilities. Ingram v. Collins, No. 23-1798, 2025 U.S. App. Vet. Claims LEXIS 327 (Vet. App. Mar. 12, 2025). The VA examinations of record have not discounted the ameliorative effects of the Veteran's steroid and Synvisc injections. Upon remand, a new examination should be obtained that discounts the ameliorative effects of medication. 3. Entitlement to service connection for gastroduodenitis is remanded. A March 2021 negative nexus opinion stated the clinician was unable to locate documentation for diagnosis or treatment for a gastrointestinal condition during service. The most recent VA medical opinion from May 2023 provided a negative nexus opinion, supported by a rationale that included a statement that found no evidence of gastroduodenitis during active duty service. However, the Veteran's STRs indicate that the Veteran experienced vomiting and abdominal pain in October 1973, a mild stomachache and vomiting in July 1975, stomach pain that was possibly gastritis in May 1982, and gastroenteritis in July 1983. Additionally, it appears that an April 2023 VA medical opinion considered the toxic exposure risk activity (TERA) of asbestos but not chemicals used for airplane repair, while the July 2023 VA medical opinion considers the Veteran's exposure to chemicals used for airplane repair but not asbestos. The duty to assist requires an opinion that considers the effects of both asbestos and the chemicals used for airplane repair. Upon remand, a new medical opinion should be obtained that considers whether the Veteran's gastrointestinal symptoms during service are related to the Veteran's current gastroduodenitis and considers the combined effects of asbestos and chemicals used for airplane repair. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of the service-connected bilateral knee disabilities. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. In so doing, the examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The examiner must discount the ameliorative effects of the medication that the Veteran takes to manage his bilateral knee disabilities, including steroid and Synvisc injections. The examiner should attempt to elicit from the Veteran any information needed to determine the level of severity of his bilateral knee disabilities when his symptoms are not relieved by medication. 2. Obtain an addendum medical opinion from an appropriate clinician regarding the etiology of the Veteran's gastroduodenitis. Copies of all pertinent records must be made available to the examiner for review. After reviewing the relevant evidence, the examiner is asked to provide the following opinions: (a.) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's gastroduodenitis is related to in-service gastrointestinal problems, to include vomiting and abdominal pain in October 1973, a mild stomachache and vomiting in July 1975, stomach pain that was possibly gastritis in May 1982, and gastroenteritis in July 1983? (b.) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that there is a nexus between the Veteran's claimed disability and the TERA of exposure to chemicals used in airplane repair, including EA-934NA, and asbestos during service? The clinician should discuss the total potential exposure through all applicable deployments; and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. Each opinion offered must be supported by a complete rationale, citing to supporting factual data and medical literature, as appropriate. If the examiner cannot provide an opinion without resort to speculation, the examiner must state why and what, if any, additional evidence would permit such an opinion to be made. M.E. Larkin Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Budd, 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.