Thursday, October 27, 2011
Agent Orange, New Leukemia Treatment Compound Tested
Hopefully this new compound will soon be available to those Veterans and their children who develop Acute Leukemia following exposure to Agent Orange.
Full article at: "Compound Found in Common Wart Treatment Shows Promise as Leukemia Therapy"
ScienceDaily (Oct. 26, 2011) — A new potential leukemia therapy targets only cancer cells, while leaving healthy cells alone. Many current chemotherapy treatments affect cancer cells and healthy cells, causing significant side effects, such as fatigue, hair loss, nausea, anxiety and depression.
"The molecules used to create this anti-leukemic agent are structurally similar to the compound found in many gout treatments and over-the-counter products used to treat warts, which also prevent cell growth."
Single Judge Application, Claim Development Must be in Neutral Manner, Austin v. Brown, 6 Vet.App. 547, 552 (1994); Mariano v. Principi, 17 Vet.App. 305, 312 (2003); Hart v. Mansfield, 21 Vet.App. 505, 508 (2007); Tyrues, 23 Vet.App. at 183
Excerpt from decision below:
"Sapcoe contends that the Board's statement of reasons or bases for its decision was inadequate because the Board relied on "inherently inconsistent" propositions regarding his history of noise exposure in assessing the probative value to be assigned to the various medical opinions of record.Id. at 12. The Court agrees that the Board's statement of reasons or bases was inadequate, albeit for different reasons."
===========================================
""However, it is equally well established that VA must develop claims and gather evidence in a neutral manner." Tyrues, 23 Vet.App. at 183; see Austin v. Brown, 6 Vet.App. 547, 552 (1994)
("[B]asic fair play requires that evidence be procured by the agency in an impartial, unbiased, and neutral manner."). Specifically, "VA may not pursue . . . development if the purpose is to obtain evidence against the claim." Hart v. Mansfield, 21 Vet.App. 505, 508 (2007). As the Court explained in Mariano v. Principi:
Because it would not be permissible for VA to undertake such additional development if a purpose was to obtain evidence against an appellant's case, VA must provide an adequate statement of reasons or bases for its decision to pursue further development where such development reasonably could be construed as obtaining additional evidence for that purpose.17 Vet.App. 305, 312 (2003) (citing 38 U.S.C. § 7104(d)(1))."
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Designated for electronic publication only
UNITED STATES COURT OF APPEALS FOR VETERANS CLAIMS
NO. 10-1606
CHARLES SAPCOE, APPELLANT,
V.
ERIC K. SHINSEKI,
SECRETARY OF VETERANS AFFAIRS, APPELLEE.
Before HAGEL, Judge.
MEMORANDUM DECISION
Note: Pursuant to U.S. Vet. App. R. 30(a),
this action may not be cited as precedent.
HAGEL, Judge: Charles Sapcoe appeals through counsel a January 15, 2010,
Board of
Veterans' Appeals (Board) decision denying entitlement to VA benefits for
bilateral hearing loss.1
Record (R.) at 3-15. Mr. Sapcoe's Notice of Appeal was timely, and the
Court has jurisdiction to
review the Board decision pursuant to 38 U.S.C. § 7252(a). Neither party
requested oral argument
or identified issues that theybelieve require a precedential decision of
the Court. Because the Board
provided an inadequate statement of reasons or bases for its decision, the
Court will vacate the
January 15, 2010, Board decision and remand the matter for readjudication
consistent with this
decision.
I. FACTS
Mr. Sapcoe served on active duty in the U.S. Air Force from February 1957
to February
1961. Prior to entering the military, Mr. Sapcoe worked as a hydraulic
press operator for 15 months.
In service, he worked as an aircraft control and warning radar repairman
and was exposed to noise
The Board also awarded Mr. Sapcoe VA benefits for tinnitus and otitis
media, and those claims, therefore, are
not the subject of this appeal. See 38 U.S.C. § 7266(a) (stating that the
Court only reviews final Board decisions adverse
to the claimant).
1
from heavy ground radar equipment and generators without hearing
protection. In October 1960,
Mr. Sapcoe perforated his right ear drum with a Q-tip and was subsequently
diagnosed with an ear
infection, for which medication was prescribed. Mr. Sapcoe's January1961
separation examination
indicates that he punctured his right tympanic membrane during service,
but that he had no
complications or sequellae from that injury at that time. Mr. Sapcoe's
ears were otherwise assessed
as normal and the results of an audiological examination revealed that his
hearingwas within normal
limits.
In June 1986, 25 years after separation from service, Mr. Sapcoe began
receiving treatment
from private physicians for various ear problems. In December 1993, Mr.
Sapcoe sought treatment
for increased ear congestion that he attributed to taking two recent
flights while he had a cold. He
was subsequently diagnosed with "high frequency neurosensory hearing loss
and eustachian tube
dysfunction." R. at 328. Mr. Sapcoe's private physicians later attributed
his hearing loss to noise
exposure in the military.
In September 2005, Mr. Sapcoe filed a claim for VA benefits for bilateral
hearing loss,
among other ear conditions. In October 2005, Mr. Sapcoe attended a VA
audiological examination.
The examination report stated that,followingservice, Mr. Sapcoe worked in
a machine shop for nine
years and periodically visited radar sites for 23 years without wearing
hearing protection. The
examiner diagnosed Mr. Sapcoe with bilateral hearing loss and opined that
it was less likely than not
related to service because his hearing was within normal limits at
separation, his hearing declined
recently, and "the greatest amount of his noise exposure appears to have
been after separation from
the service." R. at 499. Accordingly, in February 2006, a VA regional
office denied his claim for
benefits for bilateral hearing loss. Mr. Sapcoe filed a timely Notice of
Disagreement with that
decision and subsequently perfected his appeal.
In March 2006, Mr. Sapcoe submitted a letter to VA explaining that he only
worked in a
machine shop for four months, not nine years as the VA examiner stated,
and that, during the rest
of his career, he was only exposed to noise on an occasional basis. He
reiterated those assertions to
a VA examiner in April 2006 and at a regional office hearing in February
2007. In March 2007, Mr.
Sapcoe submitted another letter to VA asserting that "all of [his]
exposure to noise came from []
working with and around heavy ground radar equipment while in the [Air
Force] and hardly any
2
from [his] civilian career," and clarifying that, during the 23-year
period following service where he
periodically worked on radar sites, he "was always in a noise[-]free
environment building." R. at
344. In April 2008, Mr. Sapcoe testified at a Board hearing that his
hearing loss began "immediately
in the 1960s" and denied being exposed to noise after service. R. at 234.
In June 2008, the Board remanded Mr. Sapcoe's claim for additional
development, including
a new VA audiological examination, because (1) the private medical records
did not take into
account his pre-service noise exposure as a hydraulic press operator or
the results of his audiological
examination at separation from service; and (2) the October 2005 VA
medical examination was
based on an inaccurate history of noise exposure.
Accordingly, in February 2009, Mr. Sapcoe attended a VA medical
examination conducted
by an audiologist. The audiologist noted that the claims file contained
conflicting information
regarding the onset of Mr. Sapcoe's hearing loss and his post-service
noise exposure. After
summarizing Mr. Sapcoe's pertinent medical history and performing an
audiological examination,
the audiologist diagnosed him with bilateral sensorineural hearing loss
and opined that it was less
likely than not related to service. The audiologist also indicated that a
separate VA examination
performed by a physician was necessary to address the etiology of his
otitis media.
Consequently,inApril 2009,Mr.SapcoeunderwentaVAeardiseaseexamination
conducted
by a physician. The physician reviewed Mr. Sapcoe's claims file and
diagnosed him with bilateral
sensorineural hearing loss, among other conditions. The physician then
opined:
It is at least as likely as not that the primary etiology for the
bilateral sensorineural
hearing loss . . . is service related military noise exposure. This is due
to the amount
of noise [Mr. Sapcoe] was exposed to in the service and that he reported
the onset of
the hearing loss soon after he left the service. Furthermore, he denied
professional
or recreational noise exposure after leaving the service.
It is least likely that the Q-tip injury to the right tympanic membrane
contributed to
his hearing loss. . . . The tympanic membrane is normal and intact and the
hearing
loss is sensorineural and not conductive in nature.
R. at 155.
3
In light of those conflicting medical opinions, the Board member
requested a medical
advisoryopinion from the Veterans Health Administration to determine the
etiologyof Mr. Sapcoe's
hearing loss. In October 2009, a VA audiologist provided such an opinion:
In view of the conflicting private and VA medical opinions of record, it
is less likely
as not (less than 50/50 probability) that [Mr. Sapcoe]'s claimed hearing
loss is the
result of his active duty in the service. His separation medical
evaluation . . . is clear.
Ears were examined and considered to be normal. . . . The "Whispered Voice
Test"
was also performed and results were 15/15 bilaterally. It should be noted
that the
"Whispered Voice Test"isnotfrequencyspecificand is insensitive to high
frequency
hearing loss, the type of hearing losses most likely to occur as a result
of noise
exposure[;] however, the full [a]udiological evaluation above indicates
that hearing
was well within normal limits in the high frequency ranges bilaterally.
R. at 45.
In January 2010, the Board issued the decision currently on appeal, which,
in pertinent part,
denied entitlement to benefits for bilateral hearing loss. Specifically,
the Board discounted the
positive nexus opinions provided by Mr. Sapcoe's private physicians
because they "made no
reference to [his] pre- or post-service noise exposure, focusing [their]
attention solely on the history
of in-service noise exposure as related by[Mr. Sapcoe]," and likewise
discounted the April 2009 VA
medical opinion because the examiner "relied on [Mr. Sapcoe]'s statement
that he had no traumatic
noise exposure following his separation from service." R. at 14. The Board
noted that those
opinions failed to consider Mr. Sapcoe's post-service noise exposure while
working next to a
machine shop and at radar sites and therefore concluded that they were not
entitled to any probative
weight. Instead, the Board preferred the October 2005, April 2006, and
February 2009 VA medical
opinions because they took into account Mr. Sapcoe's pre- and post-service
employment, as well as
"the vague and sometimes inconsistent answers provided by[Mr. Sapcoe] when
questioned as to his
noise exposure." Id. The Board also favored those opinions because they
were "reinforced by the
October 2009 VA medical opinion . . . that noted the normal separation
audiometric examination."
Id. Consequently, the Board found that the preponderance of the evidence
was against Mr. Sapcoe's
claim.
4
II. ANALYSIS
Mr. Sapcoe argues that the Board erred in obtaining the October 2009
medical advisory
opinion from the Veterans Health Administration because the only purpose
for obtaining such an
opinion was to develop evidence against his claim. Specifically, Mr.
Sapcoe asserts that, prior to
the Board's request for the medical advisory opinion, he was entitled to
an award of benefits for
bilateral hearing loss pursuant to U.S.C. § 5107(b) and 38 C.F.R. § 3.
102 because the Board
implicitly found that the evidence of record was in equipoise, and that
the Board subsequently
requested the medical advisory opinion solely to "break the deadlock"
between the conflicting
February and April 2009 VA medical opinions. Appellant's Brief (Br.) at 10.
Alternatively, Mr.
Sapcoe contends that the Board's statement of reasons or bases for its decision was inadequate because the Board relied on "inherently inconsistent" propositions regarding his history of noise exposure in assessing the probative value to be assigned to the various medical opinions of record.Id. at 12. The Court agrees that the Board's statement of reasons or bases was inadequate, albeit for different reasons.
"[I]t is well established that the Board has the discretion to determine whether further development is needed to make a decision on a claim." Tyrues v. Shinseki, 23 Vet.App. 166, 182(2009) (en banc), aff'd, 631 F.3d 1380 (Fed. Cir. 2011), judgment vacated, __ S. Ct. __ (No. 10- 1405, Oct. 3, 2011). To that end, "[t]he Board may obtain a medical opinion from an appropriate health care professional in the Veterans Health Administration . . . on medical questions involved in the consideration of an appeal when, in its judgment, such medical expertise is needed for equitable disposition of an appeal." 38 C.F.R. § 20.901(a). The Court will not overturn the Board's determination that a medical opinion from the Veterans Health Administration was necessary to decide a claim unless it was "arbitrary, capricious, an abuse of discretion, or otherwise not in
accordance with law." See Stringham v. Brown, 8 Vet.App. 445, 448 (1995) ("The standard of review this Court applies to a discretionary determination made by the Secretary is whether such determination is arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with law."); see also Boutwell v. West, 11 Vet.App. 387, 391 (1998) (applying that standard of review to the Secretary's decision to obtain an independent medical examination).
5
"However, it is equally well established that VA must develop claims and gather evidence in a neutral manner." Tyrues, 23 Vet.App. at 183; see Austin v. Brown, 6 Vet.App. 547, 552 (1994)
("[B]asic fair play requires that evidence be procured by the agency in an impartial, unbiased, and neutral manner."). Specifically, "VA may not pursue . . . development if the purpose is to obtain evidence against the claim." Hart v. Mansfield, 21 Vet.App. 505, 508 (2007). As the Court explained in Mariano v. Principi:
Because it would not be permissible for VA to undertake such additional development if a purpose was to obtain evidence against an appellant's case, VA must provide an adequate statement of reasons or bases for its decision to pursue further development where such development reasonably could be construed as obtaining additional evidence for that purpose. 17 Vet.App. 305, 312 (2003) (citing 38 U.S.C. § 7104(d)(1)). The Board's
statement of reasons or
bases is adequate if it allows a claimant to understand the precise basis
for the Board's decision and
facilitates review in this Court. Gilbert v. Derwinski, 1 Vet.App. 49, 57 (
1990). The Board may
commit error requiring remand when it fails to provide such a statement.
Id.
In June 2008, the Board determined that the various private medical
opinions of record were
inadequate because the physicians who rendered them "were apparently not
made aware that[,] prior
to service, [Mr. Sapcoe] was employed for 15 months as a hydraulic press
operator; nor did the
physicians address the findings of [his] separation exam[ination] and his
January 1995 worker's
compensation claim." R. at 226. Likewise, the Board determined that the
October 2005 VA medical
examination was also inadequate because it was "apparently based . . . on
an inaccurate recounting
of [Mr. Sapcoe]'s exposure to noise through his work following the
military. It is apparent that the
examiner was also unaware that [Mr. Sapcoe] had pre-service noise exposure
as a hydraulic press
operator for 15 months." Id. (emphasis omitted). Accordingly, the Board
remanded Mr. Sapcoe's
claim for benefits for bilateral hearing loss to obtain a medical opinion "
based on the complete
claims file" that would "address and reconcile the contradictory
etiological opinions of record." Id.
Accordingly,
theBoardobtainedtheFebruary2009VAaudiologicalexaminationandtheApril2009
VA medical examination, which resulted in conflicting conclusions
regarding the etiology of Mr.
Sapcoe's hearing loss. In light of these conflicting opinions, the Board
apparently determined that
it was necessaryto obtain a medical advisoryopinion to equitablydecide the
claim. As noted above,
6
the Board has the discretion to obtain such an opinion, provided that it
adequately explains its
rationale for doing so.
Here, however, the Board made no attempt to explain why it sought the
medical advisory
opinion from the Veterans Health Administration. Rather, it simply
summarized the opinion and
found that it "reinforced" the October 2005, April 2006, and February 2009
VA medical opinions
already of record. R. at 14. Absent an explanation of why a medical
advisory opinion was
necessary, and in light of the conflicting medical evidence that the Board
could have determined was
in equipoise, the Board's decision to obtain a medical advisory opinion on
the etiology of Mr.
Sapcoe's bilateral hearing loss "reasonably could be construed as
obtaining additional evidence"
against his claim. Previous HitMarianoNext Document, 17 Vet.App. at 312. Consequently, the Court
concludes that the Board's
statement of reasons or bases for its decision to obtain a medical
advisory opinion was inadequate.
Moreover, the Board's explanation for the weight it accorded to the other
medical opinions
was also deficient for a number of reasons. First, the Board relied on the
October 2005 VA medical
opinion that the Board found to be inadequate in its June 2008 decision.
Specifically, in the Board
decision currently on appeal, the Board found that opinion to be probative
because it "noted [Mr.
Sapcoe's] pre-service employment as a hydraulic press operator, as well as
post-service noise
exposure while working next to a machine shop and as a federal worker
visiting radar sites." R. at
14. However, in the June 2008 Board decision, the Board found that another
VA medical opinion
was necessary, in part, because, the October 2005 VA medical opinion was "
apparently based . . .
on an inaccurate recounting of [Mr. Sapcoe]'s exposure to nosie through
his work following the
military" and because "the examiner was also unaware that [Mr. Sapcoe] had
pre-service noise
exposure as a hydraulic press operator for 15 months." R. at 226. These
statements are clearly
contradictory and the Board did not explain why the October 2005 VA
medical opinion, which it
previouslydeterminedwasinadequatein 2008,
wasadequateandthereforeworthyofprobativevalue
in 2010.
Second, the Board also relied on the April 2006 VA medical opinion to deny
Mr. Sapcoe's
claim for benefits for bilateral hearing loss, even though that opinion
only addressed the etiology of
his otitis media, not his hearing loss. Therefore, absent any explanation
as to why the April 2006
7
VA medical opinion was relevant to Mr. Sapcoe's claim for benefits for
hearing loss, it is entirely
unclear why the Board found that it weighed against that claim.
Finally, the Board did not explain why a failure to discuss Mr. Sapcoe's
pre-service noise
exposure rendered the private medical opinions and the April 2009 VA
medical opinion less
probative. To the extent that the Board implied that Mr. Sapcoe's pre-
service noise exposure was
responsible for his hearing loss, the Board pointed to no evidence of
record to support that
conclusion, nor did it discuss the presumptions of soundness and
aggravation. See Wagner v.
Principi, 370 F.3d 1089, 1097 (Fed. Cir. 2004). Moreover, to the extent
that the Board implied that
Mr. Sapcoe was not credible because he did not provide a complete history
of noise exposure to
those examiners, the Board made no such express credibility determination
in its decision. In short,
the Board's failure to explain the significance of Mr. Sapcoe's pre-
service noise exposure frustrates
judicial review. See Gilbert, 1 Vet.App. at 57.
Based on the foregoing, the Court concludes that the Board's statement of
reasons or bases
for its decision was inadequate. Although Mr. Sapcoe argues that reversal
is warranted, the Court
concludes that he has not carried his burden of demonstrating that "the
only permissible view of the
evidence is contraryto the Board's decision." Gutierrez v. Principi, 19
Vet.App. 1, 10 (2004) (citing
Johnson v. Brown, 9 Vet.App. 7, 10 (1996)). Rather, vacatur and remand is
the appropriate remedy
in this case because the Board failed to provide an adequate statement of
reasons or bases for its
decision. See Tucker v. West, 11 Vet.App. 369, 374 (1998).
On remand, Mr. Sapcoe is free to submit additional evidence and argument
in accordance
with Kutscherousky v. West, 12 Vet.App. 369, 372-73 (1999) (per curiam
order). See Kay v.
Principi, 16 Vet.App. 529, 534 (2002). Further, "[a] remand is meant to
entail a critical examination
of the justification for the decision" by the Board. Fletcher v. Derwinski,
1 Vet.App. 394, 397
(1991). In addition, the Board shall proceed expeditiously, in accordance
with 38 U.S.C. § 7112
(expedited treatment of remanded claims).
8
III. CONCLUSION
Upon consideration of the foregoing, the January 15, 2010, Board decision
is VACATED
and the matter is REMANDED for readjudication consistent with this
decision.
DATED: October 24, 2011
Copies to:
Scott J. Popma, Esq.
VA General Counsel (027)
9
Single Judge Application, VA May Not Develop Negative Evidence, Mariano v. Principi, 17 Vet.App. 305,312 (2003)
Excerpt from decision below:
"Consequently, the Court will vacate the Board's decision and remand the matter for readjudication. Specifically, the Board must first consider whether, given the conflicting evidence of record, an expert or independent medical opinion would be helpful. If the Board determines that additional development is necessary, it must adequately explain its reasons or bases for the decision to pursue such development. See Mariano v. Principi, 17 Vet.App. 305,
9
312 (2003) (holding that, because VA may not develop negative evidence, it "must provide an adequate statement of reasons or bases for its decision to pursue further development where such development reasonably could be construed as obtaining additional evidence
for that purpose").
Second, the Board should consider whether the competent evidence of record is in equipoise and, if so, the Board must resolve all doubt in favor of Mr. Dickerson. See 38 U.S.C. § 5107(b); Hayes v. Brown, 5 Vet.App. 60, 69 (1993) (holding that the determination that
the evidence is in equipoise is a finding of fact by the Board)."
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Designated for electronic publication only
UNITED STATES COURT OF APPEALS FOR VETERANS CLAIMS
NO. 10-2004
EUGENE H. DICKERSON, APPELLANT,
V.
ERIC K. SHINSEKI,
SECRETARY OF VETERANS AFFAIRS, APPELLEE.
Before HAGEL, Judge.
MEMORANDUM DECISION
Note: Pursuant to U.S. Vet. App. R. 30(a),
this action may not be cited as precedent.
HAGEL, Judge: Eugene H. Dickerson appeals through counsel a February 18,
2010, Board
of Veterans' Appeals (Board) decision that denied entitlement to VA
disability benefits for arthritis,
to include rheumatoid arthritis and osteoarthritis, of multiple joints. Mr.
Dickerson's Notice of
Appeal wastimely, and the Court has jurisdiction to review the Board
decision pursuant to 38 U.S.C.
§ 7252(a). Neither party requested oral argument or identified issues
that they believe require a
precedential decision of the Court. Because the Board provided inadequate
reasons or bases for its
determination that Mr. Dickerson is not entitled to benefits for
rheumatoid arthritis, the Court will
vacate that portion of the February 2010 Board decision and remand the
matter for further
development, if necessary, and readjudication consistent with this
decision. The remainder of the
Board decision will be affirmed.
I. FACTS
Mr. Dickerson served on active duty in the U.S. Navy from September 1943
to April 1946.
His service medical records reveal a diagnosis of and treatment for
rheumatoid arthritis.
In August 1969, a VA regional office denied Mr. Dickerson's claim for
benefits for
rheumatoid arthritis, finding no link between his current condition and
his in-service diagnosis. Mr.
Dickerson continuouslyappealed that decision, and in March 1979 the
Boardagaindenied his claim.
Because there was no appellate review of Board decisions at that time, the
decision became final.
In February 1985, Mr. Dickerson sought to reopen his claim. In October
1985, he advised
VA in a letter that he had received treatment for rheumatoid arthritis
since his discharge from
service, but that the physician who treated him in the 1940s and 1950s was
deceased and his records
were unavailable. He stated that he had also received treatment from "Dr.
J. H. Smith of
Christiansburg[, Virginia,] andalsoDr.
BlaylockattheLewisGaleHospitalofRoanoke,[Virginia]."
Record (R.) at 495. Mr. Dickerson reported that both doctors told him he
had chronic arthritis.
In September 1986, the regional office determined that no change was
warranted in its
previous decisionsandthatMr.Dickerson remainednon-service-connectedfor
rheumatoid arthritis.
Overthenext 20years, Mr.Dickerson repeatedlyattempted to reopen his claim,
but his claim
remained denied. Of note during this time period, Mr. Dickerson testified
at a hearing before the
regional office in September 1996. He testified that he had received
treatment from Drs. Nixon,
McClelland, Bowen, and Jones, and that all of them diagnosed him with
rheumatoid arthritis. R. at
433. He reported that Drs. Nixon, Jones, and Bowen were deceased.1
He also stated that he
currently received treatment at the Salem, Virginia, VA medical center.
In October 2006, Mr. Dickerson again sought to reopen his claim. He stated
that his current
treatment was with a rheumatologist at an unidentified VA medical center.
The record contains VA
treatment records dated between November 2004 and November 2007 from the
Salem VA medical
center. Those records contain numerous mentions of treatment for or
complaints of rheumatoid
arthritis. R. at 366, 367, 369, 374, 376, 382; see also R. at 372 ("
Rheumatology Attending Note"),
377 ("He also has an app[ointmen]t today with Rheum[atology]"), 378 ("
Rheumatology follow-up
note"), 386 ("Rheumatologyfollow-up note"); but see R. at 380 (impression
of osteoarthritis in knee
in note signed by Mr. Dickerson's reported rheumatologist), 387 (same,
except in fingers).
The record contains a September 1976 letter from Dr. McClelland stating
that his records relating to his
treatment of Mr. Dickerson in the 1960s had been destroyed in a fire, but
that he recalled treating Mr. Dickerson "for
injuries of a hip which could have been either traumatic or arthritic." R.
at 546.
1
2
In May 2007, VA advised Mr. Dickerson of the need to submit new and
material evidence
to reopen his claim. VA also requested that he advise if he had received
private treatment so that
VA could obtain those records. Mr. Dickerson responded by supplying recent
private medical
records as well as lay statements regarding his in-service condition.
In January 2008, the regional office reopened Mr. Dickerson's claim based
on VA treatment
records showing a current diagnosis of rheumatoid arthritis, but
inexplicably denied his claim
"because the evidence continues to show this condition was not incurred in
or aggravated bymilitary
service."2
R. at 266. Mr. Dickerson filed a Notice of Disagreement with that decision
and ultimately
appealed to the Board.
In September 2008, Mr. Dickerson underwent a VA medical examination in
which the
examiner was directed to "provide an opinion as to whether it is at least
as likely as not that the
veteran's rheumatoid arthritis had its onset in service, or if it is
related to the episode of rheumatoid
arthritis diagnosed in service." R. at 192. The examiner, a nurse
practitioner, reviewed and
summarized Mr. Dickerson's service medical records, as well as his private
and VA post-service
medical records. The examiner opined:
[Mr. Dickerson] indeed has a record of being treated for polyarthralgia
and a
diagnosis of rheumatoid arthritis given while in the military. He also has
a probable
diagnosis of rheumatoid arthritis via a VA disabilitygeneral medical exam
in the late
1960's. This exam, in the late 1960's, actually has x-ray evidence of a
possible
connective tissue disease, such as rheumatoid arthritis. Unfortunately[,]
there are no
The Court notes that this is the same reasoning given in VA's May 2007
notice letter regarding the submission
of new and material evidence. R. at 356. However, the initial August 1969
regional office decision denied Mr.
Dickerson's claim for lack of a link between his current condition and his
in-service diagnosis. R. at 605 ("His present
condition . . . is in no way related to the acute transitory complaints in
service."); see also R. 574 (June 1978 Statement
of the Case declining to reopen because new evidence submitted was "not
sufficient to establish continuity of symptoms
for arthritis from the claimant's separation until the present time"); 553 (
March 1979 Board decision stating, "The
complaints during service were not early manifestations of the rheumatoid
arthritis first established as a disease entity
many years after service"). Apparently, however, beginning with the July
1995 rating decision declining to reopen the
claim, VA adopted the belief that Mr. Dickerson's claim had been
previously denied due to a lack of evidence showing
"treatment for rheumatoid arthritis while on active duty or within one
year following separation from active duty." R.
at 761.
Mr. Dickerson does not challenge the characterization of the missing
element of his claim over the course of
the past four-plus decades, and, in any event, the Board decision on
appeal reopened his claim, finding that new and
material evidence had been submitted. The Court highlights these
discrepancies only to encourage the Secretary to
practice precision and consistency in his treatment of a claim and in
recounting the history of the claim's adjudication
in his brief to the Court.
2
3
records . . . confirming the actual diagnosis[,] and there are no records
of continued
treatment specifically for rheumatoid arthritis post-military discharge.
While in the
[service,] [Mr.Dickerson]hadpolyarthralgia,inflammation, swelling,
andpainin the
usual joints [in which] rheumatoid arthritis initially presents[, but t]
here doesn't
appear to be continuation of treatment for rheumatoid arthritis thereafter.
He has
received treatment for osteoarthritis in his later years by our
rheumatologist here at
the VA [medical center]. That same provider in 2001 didn't see[] any
evidence of
active rheumatoid arthritis and proceeded to treat for osteoarthritis. He
did speak to
a suggestive history of rheumatoid arthritis. On today's exam there are no
signs or
symptoms suggestive of acute or chronic rheumatoid arthritis. [Mr.
Dickerson] has
ample evidence, clinically, of osteoarthritis[,] especially to both hands
and knees.
[He] most likely had rheumatoid arthritis in his youth and this condition
went into
remission as he aged. Presently there are no signs of joint inflammation
or panus
formation (joint findings suggestive of deformityfrom chronic rheumatoid
arthritis).
Therefore, it is this examiner's opinion, based on circumstantial evidence,
that while
in the military[,] [Mr. Dickerson] had acute arthritis, most likely
rheumatoid type,
that hasn't produced significant joint damage or functional loss as
evidenced by
today's and past joint exams.
R. at 186.3
In May 2009, the Board reopened Mr. Dickerson's claim and remanded it for
additional
development. Specifically, the Board determined that "[a] remand is
necessary to clarify any
inconsistencies in the medical record with a new examination that would
include a medical opinion,
based on the record, as to the likelihood that anyarthritis, to include
osteoarthritis and/or rheumatoid
arthritis of multiple joints, is related to service." R. at 119. The Board
stated that the examiner
should conduct all tests necessary to analyze the nature and etiology of
any such
disorder(s), including any X-rays, and tests necessary to determine
whether any
suspected condition found meets clinical criteria for classification as
rheumatoid
arthritis as a chronic disorder; and if so, whether this is presently
active or in
remission.
R. at 120. The Board also directed the regional office to obtain any
outstanding private or VA
medical records relating to treatment for any kind of arthritis.
VA obtained additional VA treatment records that contain mentions of
treatment for or
complaints of rheumatoid arthritis. R. at 60 (including rheumatoid
arthritis on a "problem list" of
Arthralgia is joint pain. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 150 (
32d ed. 2012).
Polyarthralgia is "arthralgia in many different joints." Id. at 1487.
3
4
Mr. Dickerson's conditions); 64, 71, 82, 94 (noting that Mr. Dickerson
was being treated by a VA
rheumatologist and was having difficulties managing rheumatoid arthritis
with medication); 59, 66,
72, 83, 89 (noting stable, ongoing rheumatoid arthritis); 96 (listing
rheumatoid arthritis as an "active
problem"); but see R. at 51 (noting "extensive osteoarthritis" in the
hands, knees, and ankles), 97
("Rheumatology follow-up note" signed by Mr. Dickerson's reported
rheumatologist diagnosing
osteoarthritis).
In July 2009, VA requested that Mr. Dickerson complete and return an
authorization and
consent form identifying health care providers from whom relevant medical
records still needed to
be obtained. R. at 62. Later that month, Mr. Dickerson's representative
responded: "Mr. Dickerson's
medical history is already of record[;] any additional treatment
information would come from the
Salem VA medical center." R. at 61.
In December 2009, Mr. Dickerson underwent the requested VA examination,
provided by
the same nurse practitioner who conducted the September 2008 examination.
The examiner stated
that he reviewed Mr. Dickerson's claims file and recounted his medical
history. The examiner also
stated that Mr. Dickerson was being treated by a VA rheumatologist for
osteoarthritis. R. at 37.
Aftera physical examination, the examiner found "no clinical evidence of
connective tissue disease"
in Mr. Dickerson's hands, knees, elbows, ankles, or feet. R. at 39. X-rays
were taken of the left hip,
and the report revealed "[d]egenerative changes . . . in the lower lumbar
spine. Generalized
osteopenia noted. No fracture, dislocation, or other bony abnormality. The
hip joint space is well
preserved. Mineralization is good." R. at 40. The impression was "normal
hip." Id. The examiner
also reviewed a 2008 left hip x-ray for comparison, and the findings were
essentially identical.
Under "Summary of all problems, diagnoses[,] and functional effects," the
examiner noted:
"DIAGNOSIS: no radiographic evidence of left hip arthritic condition[.]
PROBLEM
ASSOCIATED WITH THE DIAGNOSIS: osteoarthritis or rheumatoid arthritis." R.
at 41. The
examiner concluded that neither osteoarthritis nor rheumatoid arthritis
caused by or due to Mr.
Dickerson's military service. With respect to rheumatoid arthritis, the
examiner stated:
[T]hereis no connection with militaryservice because there is no arthritis
of anykind
to the left hip. It is my opinion as well that the osteoarthritis
diagnosed in his hands
and other joints listed throughout his [claims] file and here at the VA [
medical
center] Salem is not the result of the acute rheumatoid arthritis
diagnosed in military
5
service in 1944. Rheumatoid arthritis is a chronic condition of
exacerbations and
remissions. There are occasions where there is an acute arthritis without
remissions.
I cannot find documented evidence of a rheumatologic exacerbation in the [
claims]
file. Consequentlymyprevious opinion stands . . . based on circumstantial
evidence,
that while in the militarythis veteran had acute arthritis, most
likelyrheumatoid type,
that hasn't produced significant joint damage or functional loss as
evidenced by
today's and past joint exams.
R. at 43.
In February 2010, the Board issued the decision on appeal. The Board first
determined that
VA satisfied its duty to assist and that no relevant outstanding evidence
had been identified. The
Board then recounted Mr. Dickerson's medical history and the medical
evidence of record, from the
in-service diagnosis of rheumatoid arthritis to the December 2009 VA
examination. The Board
noted that the questions to be answered were whether Mr. Dickerson
currently has rheumatoid
arthritis and, if so, whether that condition is related to the in-service
diagnosis of rheumatoid
arthritis. The Board relied on the September 2008 and December 2009 VA
examination reports to
conclude that Mr. Dickerson does not have a current diagnosis of
rheumatoid arthritis and that,
although Mr. Dickerson's VA treatment records show that he "complained of
pain and swelling in
his joints with a history of inflammatory arthritis and evidence of
possible rheumatoid arthritis,"
those treatment records did not contain a "clear diagnosis of rheumatoid
arthritis since service." R.
at 12. The Board also considered Mr. Dickerson's statements in support of
his claim, but found that
"[w]hile he may well believe that he has a current disability of
rheumatoid arthritis, as a layperson
. . . [he] is simply not qualified to render a medical diagnosis in this
regard." R. at 13. Accordingly,
the Board denied his claim.4
II. ANALYSIS
On appeal, Mr. Dickerson argues that the Board failed to ensure compliance
with its May
2009 remand order because the December 2009 VA examiner "did not order any
tests to determine
4
The Board also determined that Mr. Dickerson's current diagnosed
disability of osteoarthritis was not related
to service. Mr. Dickerson, however, raises no arguments related to that
decision and the Court deems any appeal of that
portion of the Board's decision abandoned. See Grivois v. Brown, 6 Vet.App.
136, 138 (1994) (holding that issues or
claims not argued on appeal are considered abandoned).
6
whether [he] has rheumatoid arthritis." Appellant's Brief (Br.) at 10. Mr.
Dickerson also asserts that
the Board provided inadequate reasons or bases for its decision to deny
his claim because the Board
failed to account for inconsistencies in the medical evidence regarding
whether he has a current
diagnosis of rheumatoid arthritis. The Court will consider each argument
in turn.
A. Compliance with May 2009 Remand Order
"[A] remand by this Court or the Board confers on the . . . claimant, as a
matter of law, the
right to compliance with the remand orders." Stegall v. West, 11 Vet.App.
268, 271 (1998). When
"the remand orders of the Board or this Court are not complied with, the
Board itself errs in failing
to [e]nsure compliance." Id. Such an error can constitute the basis for a
remand by this Court. Id.
Further, once VA has determined that a medical examination is necessary,
as was found in this case,
VA is required to ensure that the examination is adequate. See 38 C.F.R. §
4.2 (2011). If an
examination is found to be inadequate, "it is incumbent upon the rating
board to return the report as
inadequate for evaluation purposes." Id.; see also Stegall, 11 Vet.App. at
270-71 (remanding where
a VA examination was "inadequate for evaluation purposes"); Hicks v. Brown,
8 Vet.App. 417, 422
(1995) (concluding that an inadequate medical evaluation frustrates
judicial review).
Here, the Board ordered that Mr. Dickerson be provided a new VA medical
examination to
determine whether he has a current diagnosis of rheumatoid arthritis and,
if so, whether that
condition is related to service. As noted above, the Board instructed the
examiner to "conduct all
tests necessary to analyze the nature and etiology of any such disorder(s),
including any X-rays, and
tests necessary to determine whether any suspected condition found meets
clinical criteria for
classification as rheumatoid arthritis as a chronic disorder." R. at 120.
Contrary to Mr. Dickerson's claim that the December 2009 VA examiner "did
not order any
tests," Appellant's Br. at 10, the examination report clearlyshows that
the examiner ordered an x-ray
of Mr. Dickerson's left hip and lower back to determine if there was any
radiological evidence of
rheumatoid arthritis. It is clear that Mr. Dickerson believes that the
examiner was required to order
additional tests, based on information contained in VA's Adjudication and
Procedure Manual, but
the Board clearly left it to the examiner's discretion to determine what
tests were "necessary" to
provide the requested opinion. Here, the examiner exercised his discretion
to "only" order an x-ray
to inform his opinion, and Mr. Dickerson has not demonstrated that doing
so was improper.
7
Accordingly, the Court concludes that the Board ensured at least
substantial compliance with its
December 2009 remand order. See Dyment v. West, 13 Vet.App. 141, 146–47 (
1999) (holding that
there is no error when an examiner "more than substantially complie[s]
with the Board's remand
order"), aff'd sub nom. Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002).
Moreover, the examiner's purported "fail[ure] to consider the disability
factors" of
rheumatoid arthritis outlined in the Adjudication Procedures
Manual–including "dryness of the eyes
and mouth (Sjogren's syndrome), pulmonary complications, anemia,
enlargement of the spleen,
muscular atrophy, gastrointestinal symptoms, circulatory changes,
imbalance in water metabolism,
or dehydration, vascular changes, cardiac involvement, dry joints, [and]
low renal function,"
Appellant's Br. at 13–is, at best, harmless error, given that Mr.
Dickerson does not assert either that
he suffers from any of these symptoms or that the examiner overlooked
evidence of these symptoms
in his review of the medical record. See Conway v. Principi, 353 F.3d 1369,
1374 (Fed. Cir. 2004);
see also 38 U.S.C. § 7261(b)(2) (requiring the Court to "take due account
of the rule of prejudicial
error").
To the extent that Mr. Dickerson attempts to argue that, because the VA
examiner who
performed the December 2009 examination was a nurse practitioner and not a
physician, he was not
competent or knowledgeable enough to provide an adequate examination, the
Court notes that it is
well-settled that the Board is entitled to presume the competence of a VA
examiner in the absence
of evidence demonstrating otherwise. See Cox v. Nicholson, 20 Vet.App. 563,
569 (2007). Mr.
Dickerson offers nothing more than bald speculation that the examiner was
unqualified to perform
the December 2009 examination and, accordingly, has not carried his burden
of demonstrating error
on this point. See Hilkert v. West, 12 Vet.App. 145, 151 (1999) (holding
that the appellant has the
burden of demonstrating error), aff'd per curiam, 232 F.3d 908 (Fed. Cir.
2000) (table).
B. Reasons or Bases
Mr. Dickerson contends that the Board "failed to adequately explain the
inconsistencies in
the medical record as to whether [he] has a current diagnosis of
rheumatoid arthritis." Appellant's
Br. at 16. The Court agrees.
The Board stated:
8
Although several . . . treatment records indicate that the Veteran
complained of pain
and swelling in his joints with a history of inflammatory arthritis and
evidence of
possible rheumatoid arthritis, and there is evidence he was being treated
by the VA
Rheumatology Clinic, none of the treatment records contains a clear
diagnosis of
rheumatoid arthritis since service.
R. at 12. This statement is simply unsupported by the medical evidence of
record. As outlined in
Part I above, the record is replete with evidence of a current diagnosis
of rheumatoid arthritis.
Although the evidence contained in Mr. Dickerson's VA medical records
conflicts with the opinion
of the VA medical examiner who conducted the September 2008 and December
2009 VA
examinations,suchconflictdoesnot renderthosemedicalrecordsnot
probativeorincompetent. The
Board's attempt to discount the VA medical records as merely demonstrating
a "history" of
inflammatoryarthritis and "possible"rheumatoid arthritis is insufficient
in lightofthenumerousVA
treatment records that expressly state that Mr. Dickerson is being treated
for "ongoing" and "stable"
rheumatoid arthritis. This is especially important in light of the Board's
acknowledgment that
rheumatoid arthritis is a potentially chronic condition of active and
dormant states. R. at 120. The
Court concludes, therefore, that the Board has provided inadequate reasons
or bases for its
determination that Mr. Dickerson does not have a current diagnosis of
rheumatoid arthritis. See 38
U.S.C. § 7104(d)(1); Caluza v. Brown, 7 Vet.App. 498, 506 (1995), aff'd
per curiam, 78 F.3d 604
(Fed. Cir. 1996) (table).
TheCourt maynot reversetheBoard's decision,however.
DespitethenumerousVAmedical
records that indicate a current diagnosis of rheumatoid arthritis, there
is also a fair amount of
evidence that indicates that Mr. Dickerson does not, in fact, suffer from
rheumatoid arthritis, not the
least of which are the two VA examinations and the notations from Mr.
Dickerson's rheumatologist
that he is being treated for osteoarthritis. See Gutierrez v. Principi, 19
Vet.App. 1, 10 (2004)
(holding that "reversal is the appropriate remedy when the only
permissible view of the evidence is
contrary to the Board's decision"). Consequently, the Court will vacate
the Board's decision and
remand the matter for readjudication. Specifically, the Board must first
consider whether, given the conflicting evidence of record, an expert or independent medical opinion
would be helpful. If the Board determines that additional development is necessary, it must
adequately explain its reasons or bases for the decision to pursue such development. See Mariano v.
Principi, 17 Vet.App. 305,
9
312 (2003) (holding that, because VA may not develop negative evidence, it "must provide an adequate statement of reasons or bases for its decision to pursue further development where such development reasonably could be construed as obtaining additional evidence
for that purpose").
Second, the Board should consider whether the competent evidence of record
is in equipoise and,
if so, the Board must resolve all doubt in favor of Mr. Dickerson. See 38
U.S.C. § 5107(b); Hayes
v. Brown, 5 Vet.App. 60, 69 (1993) (holding that the determination that
the evidence is in equipoise
is a finding of fact by the Board).
On remand, Mr. Dickerson is free to submit additional evidence and
argument in accordance
with Kutscherousky v. West, 12 Vet.App. 369, 372-73 (1999) (per curiam
order). See Kay v.
Principi, 16 Vet.App. 529, 534 (2002). Further, "[a] remand is meant to
entail a critical examination
of the justification for the decision" by the Board. Fletcher v. Derwinski,
1 Vet.App. 394, 397
(1991). In addition, the Board shall proceed expeditiously, in accordance
with 38 U.S.C. § 7112
(expedited treatment of remanded claims).
III. CONCLUSION
Upon consideration of the foregoing, that portion of the February 18, 2010,
Board decision
that denied entitlement to VA benefits for rheumatoid arthritis is VACATED
and the matter is
remanded for further development, if necessary, and readjudication
consistent with this decision.
The remainder of the Board decision is AFFIRMED.
DATED: October 24, 2011
Copies to:
Jeany Mark, Esq.
VA General Counsel (027)
10
Single Judge Application, Symptomatology, Not Treatment, C.F.R. 3.303(b), Savage, 10 Vet.App. at 496
Excerpt from decision below:
"38 C.F.R. § 3.303(b). Continuity of symptomatology may establish service connection if a claimant can demonstrate (1) that a condition was "noted" during service; (2) there is postservice evidence of the same symptomatology; and (3) there is medical or, in certain circumstances, lay evidence of a nexus between the present disability and the postservice symptomatology. Barr, 21 Vet.App. at 307 (citing Savage v. Gober, 10 Vet.App. 488, 495-96 (1997)). "[S]ymptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet.App. at 496.
In this case, there is evidence pertaining to all three elements. There was a condition, plantar foot pain, noted in service. There is ample evidence of continuing foot pain and the 2008 VA examiner indicates that the appellant's present plantar fasciitis may explain the continuing postservice foot pain. As the Secretary concedes, the evidence produced in development of the bilateral foot disorder complaint reveals a condition that is within the scope of the filed claim, which the Board must consider. See Clemons v. Shinseki, 23 Vet.App. 1 (2009). Thus, the Court will remand the bilateral foot condition claim for development of the plantar fasciitis issue."
==================
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Designated for electronic publication only
UNITED STATES COURT OF APPEALS FOR VETERANS CLAIMS
NO. 10-2106
GREGORY B. SMITH, APPELLANT,
v.
ERIC K. SHINSEKI,
SECRETARY OF VETERANS AFFAIRS, APPELLEE.
Before DAVIS, Judge.
MEMORANDUM DECISION
Note: Pursuant to U.S. Vet. App. R. 30(a),
this action may not be cited as precedent.
DAVIS, Judge: U.S. Armyveteran GregoryB. Smith appeals through counsel
from a March
15, 2010, Board of Veterans'Appeals (Board) decision that, among other
things, found that new and
material evidence had not been submitted to reopen a previouslydenied
claim for pes planus; denied
claims for service connection benefits for (1) a bilateral foot disorder,
status post removal of
ganglion cysts and (2) a bilateral knee disorder claimed as secondary to
the pes planus condition;
and denied increased disability ratings for (1) residuals of fractures of
the right fourth and fifth
metacarpals for the period from June 23, 2003, to September 4, 2008, and (
2) a scar on the left hand
resulting from surgical removal of a ganglion cyst.1
For the following reasons, the Court will affirm
in part and set aside in part the Board's March 2010 decision and remand
four matters for further
proceedings consistent with this decision.
The Board also denied a claim for disability benefits for a condition
manifested by bilateral leg weakness and
a disability rating in excess of 10% for residuals of the right hand
fracture from September 5, 2008. The appellant
explicitly abandoned these issues on appeal and the Court will give them
no consideration. See Bowling v. Principi,
15 Vet.App. 1, 16 (2001); Green v. Brown, 10 Vet.App. 111, 115 (1997). The
Board also remanded a PTSD issue for
further development and referred an issue with respect to a disability
rating and effective date assigned for extensor
tendinitis of the left wrist. The Court has no jurisdiction over those
matters because they are not the subject of a final
Board decision. See Hampton v. Gober, 10 Vet.App. 481, 483 (1991); Link v.
West, 12 Vet.App. 39, 47 (1998).
1
I. ANALYSIS
A. Bilateral Pes Planus (Flat Feet)
The appellant had active duty service from January 19, 1984, to March 15,
1989. His
induction examination contained a notation indicating "[p]es [p]lanus, Mod
. [moderate],
asymptomatic." Record (R.) at 1820. As the Board acknowledged, "[s]ervice
treatment records show
that he received treatment for pain in his feet on numerous occasions due
to various causes and at
times was placed on temporary limited duty profiles." R. at 10. Notably,
one document reported:
"B/L [bilateral] arch pain [and] plantar foot pain." R. at 2152. A
previous Board decision noted that
"neither a report of examination prior to separation, nor a report of
medical history filled out prior to
separation [is] contained in the claims folder." R. at 622.
In June 2003 the appellant filed a claim that sought benefits for a "
bilateral foot condition."
R. at 2269. The regional office (RO) developed this claim as "bilateral
pes planus and athritis," but
denied the claim in January2004 on the basis that "service medical records (
SMRs) . . . failed to show
evidence of worsening of [the] pes planus and are negative for any
clinical findings, treatment or
diagnosis of arthritis." R. at 2179-80. On appeal, a 2007 Board decision
found that the medical
evidence of record "preponderate[d] against a finding that the veteran's
bilateal pes planus that
preexisted service was permanently worsened therein; or that arthritis of
the feet was diagnosed
within one year after separation from service." R. at 615. This decision
became final.
After receiving a statement in support of the claim on January 17, 2008,
the RO sent notice
letters with regard to the pes planus claim and provided a VA medical
examination in June of that
year. Apparently, the RO reopened the claim but denied it on the merits,
on the basis that "the
evidence still does not show that [the] bilateral pes planus either [was]
incurred in or was aggravated
by military service." R. at 216. In the decision here on appeal, however,
the Board found that the
evidence submitted since the last prior denial "does not raise a
reasonable possibilityof substantiating
the claim for service connection for bilateral pes planus," and concluded
that new and material
evidence had not been submitted to reopen the claim. R. at 6-7.
1. Adequacy of VA Medical Examination
The appellant first argues that the June 2008 VA medical examination, on
which the Board
principally relied, was inadequate for failure to opine on whether his pes
planus had been aggravated
2
during service. "[O]nce the Secretary undertakes the effort to provide an
examination . . . he must
provide an adequate one or, at a minimum, notify the claimant why one will
not or cannot be
provided." Barr v. Nicholson, 21 Vet.App. 303, 311 (2007). A medical
examination is adequate
"where it is based upon consideration of the veteran's prior medical
historyand examinations and also
describes the disability, if any, in sufficient detail so that the Board's
'evaluation of the claimed
disability will be a fully informed one.'" Stefl v. Nicholson, 21 Vet.App.
123, 123 (2007) (quoting
Ardison v. Brown, 6 Vet.App. 405, 407 (1994)). The report must contain
clear conclusions and
supporting data, as well as "a reasoned medical explanation" connecting
the data and conclusions.
Nieves-Rodriguez v. Peake, 22 Vet.App. 295, 301 (2008).
The adequacyof a medicalexamination is a factual determination reviewed
under the "clearly
erroneous" standard of review. See Nolen v. Gober, 14 Vet.App. 184 (2000).
A finding is clearly
erroneous when, although there is evidence to support it, the reviewing
court on the entire evidence
is left with the definite and firm conviction that a mistake has been
committed. Gilbert v. Derwinski,
1 Vet.App. 49, 52 (1990). The Court agrees with the appellant that the
2008 VA examination report
was inadequate, for at least two distinct reasons.
i. Appropriate Classification of Congenital Condition
First, the June 2008 report failed to provide the Board with a description
of the appellant's
condition sufficient to allow the Board to make an informed classification
of the appellant's pes
planus disability and nothing in the record before the Court remedies that
deficiency. In its 2007
decision, the Board referred to a May 2006 VA examination report and
stated: "the VA examiner
diagnosed congenital pes planus." R. at 623. This examination report is
not contained in the record
before the Court, but accepting the Board's characterization of its
content, the report stated only that
the condition was congenital.
As the Court has noted, "the mere fact that a condition is the result of a
congenital cause does
not necessarily mean that the condition itself manifested before service
or that it was not aggravated
by service." Quirin v. Shinseki, 22 Vet.App. 390, 394 (2009). The Court
went on to discuss the
difference between congenital diseases, to which the presumptions of
soundness and aggravation
attach, and congenital defects, to which these presumptions do not apply.
See 38 C.F.R. § 3.303(c)
(2011) ("Congenital or developmental defects . . . are not diseaes or
injuries within the meaning of
3
of applicable legislation."). The Court noted that a General Counsel
opinion on the subject
distinguishes the two classes of disabilities on the basis that "'a defect
differs from a disease in that
the former is "more or less stationary in nature" while the latter is "
capable of improving or
deteriorating."'" Quirin, 22 Vet.App. at 394 (quoting VA Gen. Coun. Prec.
82-90 (July 18, 1990)).
The Court further noted that "any worsening–any change at all–might
demonstrate that the condition
is a disease, in that VA considers defects to be 'more or less' static and
immutable." Id. at 395. The
Court recommended that the Board obtain medical opinions to assist in the
process of properly
classifying the congenital conditions.
Without such an appropriate classification, the Board is not in a position
to determine which
party has the burden of proof and what standard of proof applies. If the
appellant's pes planus is a
preexisting congenital disease, the appellant must first show that the
disability increased during
service and the Secretary must then prove, by clear and unmistakable
evidence, that the increase was
due to the "natural progress of the disease." Wagner v. Principi, 370 F.3d
1089 (Fed. Cir. 2004). On
the other hand, if the condition is a congenital defect, the appellant
would have the burden of
establishing all the elements of an aggravation claim, under the equipoise
standard of 38 U.S.C.
§ 5107(b), without benefit of the presumption. See G.C. Prec. 82-90 at 3
("[M]any [congenital]
defects can be subject to superimposed disease or injury . . . [in which
case] service-connection may
indeed be warranted for the resultant disability.").
The Board must also include in its decision a written statement of the
reasons or bases for its
findings and conclusions on all material issues of fact and law presented
on the record. That
statement must be adequate to enable an appellant to understand the
precise basis for the Board's
decision and to facilitate informed review in this Court. See 38 U.S.C. §
7104(d)(1); Allday v. Brown,
7 Vet.App. 517, 527 (1995); Gilbert, 1 Vet.App. at 56-57.
The 2008 VA examination report was inadequate to support the Board's
reasoning on the
classification of the appellant's pes planus. In the decision here on
appeal, the Board apparently
concluded that the appellant's pes planus was a congenital defect. The
Board stated:
The evidence of record received since January 2007, specifically the June
2008 VA
examination report, does not reflect the congenital bilateral pes planus
increased in
severity due to his time in service. A congenital defect is not an injury
or disease for
VA compensation puposes. . . There was no showing of superimposed
pathology at
4
thetime ofthe[2007] Boarddecisionandnoneshowninevidencereceivedsincethen.
R. at 12 (citation omitted). The Board offered no explanation for its
apparent conclusion that the
appellant's pes planus was a congenital defect, as opposed to a congenital
disease. There is no
discussion of this matter in the June 2008 medical examination report and
the Board does not discuss
any medical evidence elsewhere in the record that would support such a
conclusion. Therefore, it is
an inappropriate medical conclusion on the part of the Board. See Colvin v.
Derwinski, 1 Vet.App.
171 (1991).
ii. Lack of Evidence on Aggravation
Second, the Court agrees with the appellant that the 2008 VA medical
examination report
contained no discussion whether there was a worsening of the appellant's
pes planus in service, much
less an increase in disability. The report stated only that the
appellant's "[p]es planus (bilaterally) is
at least as likely as not (50/50 probability) the same as seen in military
service." R. at 257. This
statement pertains to a nexus requirement. The opinion says nothing about
the critical question,
which is whether the appellant's pes planus worsened to the point of an
increased disability during
his service. The examination is therefore inadequate for failure to
describe the disability in sufficient
detail to inform the Board as to the salient issue. Having undertaken to
provide a medical
examination, the report must be adequate. See Barr, supra.
In sum, the Board erred in relying on the June 2008 VA examination report
and the Board's
statement of reasons or bases is inadequate. The Court will set aside the
Board's finding that new and
material evidence was not submitted to reopen the claim for benefits for
pes planus and remand the
issue for the Board to obtain additional medical evidence and provide a
revised statement of reasons
or bases. The Secretary further concedes, and the Court agrees, that the
claims for benefits for
bilateral knee disorders are inextricably intertwined with the pes planus
claim. Accordingly, the
Court will set aside the Board's findings on these matters and remand them
also.
2. Adequacy of VCAA Notice
The appellant further argues that the VA notice letters on which the Board
relied failed to
satisfy the requirements of the Veterans Claims Assistance Act of 2000 (
VCAA), Pub. L. No. 106-
475, § 3(a), 114 Stat. 2096 (codified in part at 38 U.S.C. § 5103(a)).
Specifically, he argues that the
5
letter pertaining to the pes planus condition inaccurately described the
reason for the 2007 Board
denial and, consequently, the issue to which his evidence must be directed.
This Court has indicated that VCAA notice must be tailored to the nature
of the claim. See
Kent v. Nicholson, 20 Vet.App. 1 (2006). In the case of a claim to reopen,
the Secretary must "look
at the bases for the denial in the prior decision and . . . [provide] a
notice letter that describes what
evidence would be necessary to substantiate that element or elements
required to establish service
connection that were found insufficient in the previous denial." Id. at 10.
The Secretary concedes that "the June 2007 notice letter (the only one
addressing new and
material evidence) misinformed the Appellant of the prior basis for denial,
rendering it inadequate."
Secretary's Brief at 5. The Court agrees with the concession. The VCAA
notice letter mentioned only
the reason for the previous denial of service connection for arthritis; it
said nothing about the reason
for the denial of service connection for bilateral pes planus.
Because the Board declined to reopen the claim based on a lack of new and
material evidence
directed to an increase in disability, the Court is unable to conclude
that the error did not prejudice
the appellant. See 38 U.S.C. § 7261(b)(2) (directing Court to take due
account of the rule of
prejudicial error). He correctly argues that had the notice been correctly
given he could have sought
and obtained a medical opinion that addressed the issue of in-service
aggravation. Therefore, the
Court must remand the issue of new and material evidence to reopen the
claim for benefits for pes
planus for this reason as well.
B. Bilateral Foot Disorder
The appellant further argues that the Board erred in finding that "
theexaminer did not find any
objective evidence of a current disability" with regard to the claim for
benefits for a bilateral foot
disorder. R. at 15. The June 2008 examiner's report acknowledges that the
SMRs contain a record
of removal of ganglion cysts in service. The examiner diagnosed "[p]lantar
fasciitis right foot" (R.
at 240), and noted complaints of pain in both feet. The examiner further
opined: "Bilateral feet s/p
[status post] removal of ganglion cyst (no residuals) is the same as seen
in military service but does
not account for his current feet pain since the cyst was removed in
service . . . . The veteran's plantar
fasciitis is not caused by or a result of military experience." R. at 257.
As a rationale for his opinion,
the examiner elaborated as follows:
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After surgical removal of the ganglion cyst[s] they did not re-occur. The
veteran
currently has no ganglion cyst and therefore [they] cannot be the cause of
his foot
pain . . . The veteran's plantar fasciitis was not noted in the medical
records in service
and therefore is not caused by or a result of military service.
Id. The examiner's rationale is sufficient to establish that the
appellant's present foot condition is not
linked to the in-service treatment for ganglion cysts.
As noted previously, however, the SMRs do contain evidence of in-service
plantar foot pain
(see R. at 2152), and thus may support service connection by continuity of
symptomatology. See
38 C.F.R. § 3.303(b). Continuity of symptomatology may establish service connection if a claimant can demonstrate (1) that a condition was "noted" during service; (2) there is postservice evidence of the same symptomatology; and (3) there is medical or, in certain circumstances, lay evidence of a nexus between the present disability and the postservice symptomatology. Barr, 21 Vet.App. at 307 (citing Savage v. Gober, 10 Vet.App. 488, 495-96 (1997))."[S]ymptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet.App. at 496. In this case, there is evidence pertaining to all three elements. There was a condition, plantar foot pain, noted in service. There is ample evidence of continuing foot pain and the 2008 VA examiner indicates that the appellant's present plantar fasciitis may explain the continuing postservice foot pain. As the Secretary concedes, the evidence produced in development of the bilateral foot disorder complaint reveals a condition that is within the scope of the filed claim, which the Board must consider. See Clemons v. Shinseki, 23 Vet.App. 1 (2009). Thus, the Court will remand the bilateral foot condition claim for development of the plantar fasciitis issue.
C. Residuals of Right Hand Fracture
The appellant further argues that the Board erred in failing to assess the
effect of reported
flareups in his right hand, which allegedlylimit his abilityto grasp tools
and perform certain activities
such as fishing. This asserted error pertains to the rating period from
June 23, 2003, to September
4, 2008. Although the Board acknowledged the reported flareups, it stated: "
The VA examiner,
however, reported that repeated motions of the hand and fingers had no
effect on the Veteran's range
of motion, fatigability, weakness, endurance or incoordination." R. at 24.
As the appellant argues and the Secretary concedes, the Board conflated
the concepts of
flareups with the effects of repetitive motion on the day of the
examination. That the examiner
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observed no range of motion effects does not account for the reported
flareups in the absence of
evidence that the examination was conducted during such a flareup. The
Court has indicated that
certain conditions subject to flareups must be assessed during a period of
flareup. See Ardison v.
Brown, 6 Vet.App. 405, 408 (1994). The Secretary has essentially conceded
the applicability of this
decision to the facts of this case. Accordingly, the Court will set aside
the Board's findings with
respect to the disability rating for the right hand in the period from
June 23, 2003, to September 4,
2008, and remand this matter for further consideration.
D. Scar on Left Hand
As the Board noted, the rating criteria for scars was amended during the
pendency of the
apepllant's claim for benefits for residuals of his in-service hand
surgery to remove a ganglion cyst.
The appellant argues that the Board further erred in failing to apply the
current provisions of
38 C.F.R. § 4.118, Diagnostic Code (DC) 7800 in rating the effects of the
scar on his left hand. This
DC provides for a minimum 10% rating for disfigurement of the head, face,
or neck if a scar is
present having a width "at least one-quarter inch (0.6 cm.) wide at widest
part." 38 C.F.R. § 4.118,
DC 7800 (2011). In his reply brief, he intimates that a veteran previously
rated under DC 7805 can,
under the revised provisions of § 4.118, request review under DC 7800.
See Appellant's Reply Brief
at 5.
The Secretary reiterates the Board's analysis that "although a claimant
may request
consideration under the amended criteria, the Veteran has not requested
such consideration." R. at
25. The appellant responds that there is no need to make such a formal
request for a pending claim
and that the revised criteria are applicable under Karnas v. Derwinski, 1
Vet.App. 308 (1991),
overruled in part by Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003).
Without resolvingthat issue, the Court notes that it is entirelyunclear
how the appellant might
obtain a higher rating for a scar on his hand by application of a DC
directed to disfigurement of the
head, face, or neck. Neither the previous version nor the present version
of DC 7805, under which
the appellant was rated, contain any indication that the provisions of DC
7800 might apply to a rating
of scars on the hand. Therefore, the Court concludes that the appellant
has not carried his burden of
demonstrating error and pleading with some particularity the allegation of
error so that the Court is
able to review and assess the validity of the appellant's arguments. See
Coker v. Nicholson, 19
8
Vet.App. 439, 442 (2006), rev'd on other grounds sub nom. Coker v. Peake,
310 F. App'x 371 (Fed.
Cir. 2008) (per curiam order); Hilkert v. West, 12 Vet.App. 145, 151 (1999
) (en banc). The Court will
therefore affirm the Board's findings with respect to the disability
rating for the left hand.
II. CONCLUSION
Based on the foregoing, the Court AFFIRMS the March 15, 2010, Board
determination with
respect to disability rating for the scar on the appellant's left hand,
SETS ASIDE the determinations
finding that new and material evidence had not been submitted to reopen
the claim for benefits for
bilateral pes planus, denying service connection for bilateral knee
disorders, denying service
connection for bilateral foot disorders, and denying a compensable
disability rating for residuals of
fractures of right fourth and fifth metacarpals. The Court REMANDS these
four set aside matters for
further proceedings consistent with this opinion.
On remand, the appellant will be free to submit additional evidence and
argument in support
of his claims for benefits in the remanded matters, and the Board is
required to consider any such
evidence and argument. See Kay v. Principi, 16 Vet.App. 529, 534 (2002). A
final Board decision
following the remand herein ordered will constitute a new decision that,
if adverse, may be appealed
to this Court upon the filing of a new Notice of Appeal with the Court not
later than 120 days after
the date on which notice of the Board's new final decision is mailed to
the appellant. Marsh v. West,
11 Vet.App. 468, 472 (1998).
DATED: October 24, 2011
Copies to:
Davis J. Lowenstein, Esq.
VA General Counsel (027)
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