Source: http://www.danaise.com/mu-v-shinseki-09-3570/
Timestamp: 2019-04-25 16:42:52+00:00

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The Board’s finding that no nexus is found between Veteran’s disability due to Rheumatoid Arthritis and his service in Korea is clearly erroneous and therefore must be reversed?
The Board failed to assist Appellant (Veteran’s spouse).
Whether the Board’s finding that no nexus is found between Veteran’s disability due to Rheumatoid Arthritis and his service in Korea is clearly erroneous and therefore must be reversed?
In the alternative whether the Board failed to assist Appellant (Veteran’s spouse)?
Mr. Arthur U, (hereinafter, Veteran), had active military service from July 1953 to July 1956. He served at time of war in Korea. (R. 4). He was awarded 100% non-service-connected disability for Rheumatoid Arthritis in 1982. (R. 587). Veteran died in June 2005 from complications of Rheumatoid Arthritis. (R. 52). Mrs. Margaret U, Veteran’s surviving spouse, is appellant in this matter (hereinafter, appellant).
This matter came to the Board of Veterans’ Appeals (hereinafter, the Board) on appeal from a December 2005 rating decision rendered by the Seattle, Washington, Regional Office (RO) of the Department of Veterans’ Affairs (VA), which denied appellant’s claim for entitlement to service connection for Veteran’s cause of death. The Board found that Veteran did die from complications of Rheumatoid Arthritis but found no service connection. (R. 3).
Musculoskeletal findings were marked as normal on Veteran’s service enlistment examination report dated in April 1953. (R. 36).
Sick call treatment records show that from May 27, 1954, to approximately June 1, 1954, and on April 3, 1955, Veteran complained of, and was treated for, a sprained back and sore back. (R. 41).
In July 1956, Veteran’s service discharge examination report noted no back complaints or pathology. (R. 42).
The Board found that the earliest actual diagnosis of Rheumatoid Arthritis was made in 1960. (R. 42).
A March 1982 VA hospital summary report reflected a diagnosis of longstanding active Rheumatoid Arthritis since 1960. Veteran’s Rheumatoid Arthritis factor was again noted to be positive. A chest x-ray was noted to show heavy bronchovesicular markings in both bases, which was typical of Rheumatoid Arthritis. (R. 988).
In an August 1982 statement, Veteran indicated that he had experienced a great deal of pain in his shoulders and back during service.
A May 1968 private clinical record from Nehalam Bay Medical Center reflected findings of arthritis of multiple joints. (R. 10).
An April 1973 serology report revealed a positive Rheumatoid Arthritis factor. (R. 11).
A June 1977 treatment note from Mason General Hospital also revealed a positive Rheumatoid Arthritis factor. (R. 12).
In an August 1989 statement, a private physician, R. L. Y., M.D., listed a diagnosis of active and advanced Rheumatoid Arthritis. It was further noted that Veteran was totally disabled due to fibrosis of the lung secondary to Rheumatoid Arthritis. (R. 52).
Veteran died in June 2005. His death certificate listed the immediate cause of his death as respiratory failure, due to or as a consequence of pulmonary fibrosis. (R. 52).
During the July 2008 hearing, appellant asserted that Veteran experienced problems with his joints right after discharge from service and began to receive treatment in 1957. She further reported that at that time she had to begin helping Veteran to shave, to tie his shoes, and to brush his hair. Appellant further testified that, upon discharge from the service, Veteran moved to Washington State to be close to medical care for arthritis. She testified that the VA informed her that Veteran’s medical records, including the record of hospitalization in Japan and the record of care in 1956-1960, were lost in a fire. (R. 12).
developed Rheumatoid Arthritis while in service, but noted that there were only very short notations of his Infirmary visits and no clear trail of evidence. The physician also noted that any tests pointing to a diagnosis of Rheumatoid Arthritis while in service were not performed by the examining physicians, and that such testing in 1954-56 would have been rudimentary at best. (R. 12).
In a March 2009 letter, the Board requested that another VA physician, Dr. Jay E. Persselin, provide a medical advisory opinion. In April 2009, Dr. Persselin concluded that there was less than a 50 percent probability that Veteran’s Rheumatoid Arthritis had its initial clinical presentation during service or within one year after separation from service. (R. 16).
Dr. Persselin stated that he reviewed the contents of 3 volumes of the claim file, but he admitted that he had not seen any of the records which were pertinent to the question of whether or not Rheumatoid Arthritis had occurred or had been aggravated during Veteran’s service or upon discharge from the service.
Dr. Persselin agreed that there is no single presentation of Rheumatoid Arthritis. He also agreed that rheumatoid factor antibodies may initially be negative at the time of presentation and may ultimately be found positive. He also agreed that there are several well recognized initial presentations, and that less common presentations sometimes result in delaying the diagnosis. The expert went on to delineate the typical characteristic textbook presentation of Rheumatoid Arthritis, but did not adequately research the presentation of back involvement in Rheumatoid Arthritis. (R. 16).
Dr. Persselin admitted that Rheumatoid Arthritis can result in inflammation of the apophyseal joint (the joint linking the posterior articulation of adjacent vertebral bodies of the spine). He noted that in the 1982 discharge summary, a reference was made to scoliosis of the lumbosacral spine, and that a lumbosacral x-ray in May 1989 noted retro scoliosis of lumbosacral spine with convexity of the right as well as grade II spondylolisthesis L5-S1 and sclerotic appearing apophyseal joints also involving the L5-S1 region with traction osteophytes at L2-L3. Some sacroiliac joint sclerosis symmetrical was also noted. The expert conceded that Rheumatoid Arthritis could possibly explain the sclerotic changes described in L5-S1 region. Dr. Persselin concluded, however, that back involvement is rare in Rheumatoid Arthritis, and opined that there is less than 50% probability that the veteran’s Rheumatoid Arthritis had its initial clinical presentation during the time he was in the service or was present within 1 year after separation from the service.
Based on Dr. Persselin’s opinion, the Board held that Dr. Shaw’s opinion was speculative. (R. 17).
In rejecting any nexus between Veteran’s cause of death and his military service, the Board violated several rules established by the VA.
The Board rejected the testimony of Veteran’s treating physician who opined with considerable certainty that Veteran suffered from Rheumatoid Arthritis during military service. The Board explained that they did so because the physician had pointed out the obvious findings that most of the pertinent medical records were lost. The Board inferred that the entire testimony was speculative in violation of McLendon, 20 Vet. App. at 85.
, 9 Vet. App. 441, 444 (1996).
The Board had no right to seek another medical opinion from a veteran hospital physician, since Dr. Shaw is the medical director and Chief of a VA facility. See Mariano v. Principi, 17 Vet. App. 305, 312 (2003). The Board should have contacted Dr. Shaw before it ordered another exam for the sole purpose of defeating Dr. Shaw’s opinion.
The Board accepted Dr. Jay Persselin’s opinion that back pain is an unusual symptom of Rheumatoid Arthritis. Review of the medical literature shows that this conclusion is incorrect, and that back pain is not as rare as the expert led the Board to believe.
The Board had a duty to contact Dr Shaw to alert him that his opinion that Veteran’s back pain while in service was a presenting symptom of Rheumatoid Arthritis was considered speculative in view of Dr. Persselin’s opinion. The Board should have provided Dr. Shaw with Dr. Persselin’s opinion and should have asked for rebuttal. It is assumed that Dr. Shaw would have provided the Board with citations of medical treatises negating Dr. Persselin’s conclusions.
, 1 Vet. App. 428 (1991).
After obtaining the opinion of Dr. Persselin, the Board sent it to appellant (Veteran’s wife) and asked her to respond. The Board was fully aware that appellant was unrepresented. Indeed the Board held that appellant is lacking any medical expertise.
Gambill v. Peake, 2008 U.S. App. Vet. Claims LEXIS 480 (U.S. App. Vet. Cl., Apr. 28, 2008).
It is important to contrast the testimony of both experts. Dr. Shaw is a medical director of a VA facility. He had treated Veteran and had obtained a medical history from Veteran and his wife (appellant). Dr. Shaw admitted that few medical records from 1953 to 1960 had survived, a fact which should not have come as a great surprise to the Board, since the VA had already reported that those records had been destroyed in a fire.
The Board could not make a nexus decision based on the 1953-1960 medical records. Instead, it chose to rely solely on the published medical literature. As such it chose to accept as true Dr. Persselin’s statement that back pain is not a symptom of Rheumatoid Arthritis. The Board held as speculative Dr. Shaw’s opinion that back pain is indeed a symptom of Rheumatoid Arthritis.
“An IME opinion is only that, an opinion. In an adversarial proceeding, such an opinion would have been subject to cross-examination on its factual underpinnings and its expert conclusions. The VA claims adjudication process is not adversarial, but the Board’s statutory obligation under 38 U.S.C. 7104(d)(1) to state “the reasons or bases for [its] findings and conclusions” serves a function similar to that of cross-examination in adversarial litigation. The BVA cannot evade this statutory responsibility merely by adopting an IME opinion as its own, where, as here, the IME opinion fails to discuss all the evidence which appears to support appellant’s position. Accordingly, the BVA decision here contained “neither an analysis of the credibility or probative value of the evidence submitted by and on behalf of appellant in support of [her] claim nor a statement of the reasons or bases for the implicit rejection of this evidence by the Board.”” Gilbert, 1 Vet. App. at 59.
The fact that Dr. Shaw noted that few medical records from 1953-1960 survived does not contradict his testimony that, as evidenced by the medical literature, back pain is not uncommonly seen in Rheumatoid Arthritis, and that, based on the totality of Veteran’s medical history known to him through his years of caring for Veteran, he was led to the conclusion that probably, that is with considerable certainty, Veteran suffered from Rheumatoid Arthritis while in the service.
20 Vet. App. 79, 81 (2006), this Court held that medical evidence that is too speculative to establish nexus is also insufficient to establish a lack of nexus; a VA medical examination must be undertaken to resolve the nexus issue. Id. (citing Forshey v. Principi, 284 F.3d 1335, 1363 (Fed. Cir. 2002) (Mayer, C.J., and Newman, J., dissenting) (“The absence of actual evidence is not substantive ‘negative evidence.’”) It should be noted that both McLendon and the applicable statutes require some assessment of probability, as opposed to a definitive statement of the cause of the disabilities. See McLendon, 20 Vet. App. at 85; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990) (Veteran prevails when evidence supports claim or is in relative equipoise.) If the physician is able to state that a link between a disability and an in-service injury or disease is “less likely than not,” or “at least as likely as not,” he or she can and should give that opinion; there is no need to eliminate all lesser probabilities or ascertain greater probabilities.
Dr. Persselin stated that he reviewed the contents of 3 volumes of the claim file, but he admitted that he had not seen any of the records which were pertinent to the question of whether or not Rheumatoid Arthritis had occurred or had been aggravated during Veteran’s service or upon discharge from the service. Dr. Persselin agreed that there is no single presentation of Rheumatoid Arthritis. He also agreed that rheumatoid factor antibodies may initially be negative at the time of presentation and may ultimately be found positive. He also agreed that there are several well recognized initial presentations, and that less common presentations sometimes result in delaying the diagnosis. The expert went on to delineate the typical characteristic textbook presentation of Rheumatoid Arthritis, but did not adequately research the presentation of back involvement in Rheumatoid Arthritis.
Sakai, et al., from the University of Tokushima in Japan, reviewed 104 patients suffering from Rheumatoid Arthritis who presented with moderate arthritis. 47 of the patients, or 45.2%, exhibited a lumbar lesion on an MRI with changes including either disc narrowing or disc ballooning.
AWB Heywood, et al., published a study in the Journal of Bone and Joint Surgery, the official publication of the British Society of Bone and Joint Surgery. The author suggested that synovitis probably starts in the apophyseal joints slowing eroding cartilage and subchondral bone in exactly the same way as it does in peripheral joints. The author listed 8 published reports linking lumbar and thoracic vertebral disease with Rheumatoid Arthritis from 1952-1986. The author also ventured that the incidence of patients with back pain who are not in advanced degree of Rheumatoid Arthritis clearly must be higher.
H. Sims-Williams, et al., noted that in contrast with the neck, involvement of the lumbar spine in Rheumatoid Arthritis has received little attention. They observed in their patient population that radiologic manifestations of rheumatoid changes were present in the lumbar spines of 5% of males and 3% of females.
The Court should also take judicial notice that Rheumatoid Arthritis of the back is reported in veterans. Dr. Donald Resnick of the Department of Radiology, Veterans Administration Hospital, San Diego, California, described thoracolumbar spine abnormalities in veterans suffering from Rheumatoid Arthritis.This Court recently heard the case of a veteran appealing his denial for Rheumatoid Arthritis of the back.
After obtaining the opinion of Dr. Persselin, the Board sent it to appellant (Veteran’s wife) and asked her to respond. The Board was fully aware that appellant was unrepresented. Indeed the Board held that appellant is lacking any medical expertise. We argue that pursuant to the VJRA, the Board had a duty to advise appellant as to how to respond to Dr. Persselin’s opinion. At a minimum, the Board had a duty to inform appellant that, based on Dr. Persselin’s report, they were inclined to believe that Rheumatoid Arthritis does not affect the spine, and to advise her to obtain a rebuttal from Dr. Shaw.
In Layno v. Brown,6 Vet. App. 465 (1994), the CAVC ruled that when a claimant’s service medical records were destroyed or lost, the VA is under a duty to advise the claimant to obtain other forms of evidence. In Patton v. West, 12 Vet. App. 272 (1999), the CAVC held that during personal hearings conducted by VA adjudicators, pursuant to 38 C.F.R. 3.103(c), the VA has the responsibility to “suggest the submission of evidence which the claimant may have overlooked and which would be of advantage to the claimant’s position.” Accordingly, if the claimant or the records in the claims file put the VA on notice of the existence of evidence that may help substantiate the claim, the VA is required to obtain the evidence itself or advise the claimant to submit the evidence.
Once the claimant has met his burden under 5107(a) of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded, the burden then shifts to the Secretary to “assist such a claimant in developing the facts pertinent to the claim.” 38 U.S.C. 5107(a).
Hams v. West, 1998 U.S. Vet. App. LEXIS 908 No. 96-592 (1998), is a case almost identical to the case at bar involving a Veteran with Rheumatoid Arthritis of the back.
Twenty-eight years after his discharge, the veteran applied for service connection for arthritis of the knees and back. The veteran submitted a letter from Dr. Skogerboe, his treating physician, concerning the doctor’s treatment of him in 1954. The letter was at odds with the physician’s 1954 records which failed to discuss Rheumatoid Arthritis. The medical records from the years during which the physician had treated appellant were no longer maintained. The court vacated the Board’s decision. The Court reasoned that a recent letter indicated that the veteran was treated for the condition within one year of his service; therefore, his claim was well-grounded. 38 U.S.C. 5107(a). In view of the conflict between the doctor’s certificate and other medical records, the Board had a duty to develop the case further. The Court reasoned: “When an appellant presents a claim for VA benefits and supports the claim, VA has a duty to assist appellant in developing the facts pertinent to the claim.” 38 U.S.C. 5107(a); see Allday v. Brown, 7 Vet. App. 517, 526 (1995); Littke v. Derwinski, 1 Vet. App. 90, 91-92 (1990); Murphy, 1 Vet. App. at 81-82. The record does not indicate that the VA made any effort to contact Dr. Skogerboe and to ask him to explain the apparent inconsistency between his 1954 medical certificate and his 1983 letter. Such evidence would clearly be relevant to the central issue in appellant’s claim. Similarly, in our case remand is necessary to allow the Board to contact Dr. Shaw.
At the heart of the argument is Veteran’s constitutional right to confront the expert who provided the opinion relied on by the Board. In Gambill v. Peake, 2008 U.S. App. Vet. Claims LEXIS 480 (U.S. App. Vet. Cl., Apr. 28, 2008), the Court held that the US Constitution’s Due Process Clause applies to such proceedings. See also Cushman v. Shinseki, No. 2008-7129, 576 F.3d 1290, 2009 U.S. App. LEXIS 17848 (Fed. Cir. Aug. 12, 2009). Mr. Gambill argued that the Due Process Clause is not satisfied by giving the veteran the opportunity to respond to an opinion from a VHA medical professional or an independent medical examiner, but that the veteran must be given an opportunity to confront any physician who submits a medical opinion which the veteran regards as contrary to his interests in whole or in part. The submission of interrogatories, he contended, is the minimum necessary to satisfy his due process right to confront the evidence against him.
Although interrogatories may not always be necessary, clearly the conclusion regarding the case at bar is that the Board cannot meet its duties by merely sending the report of the expert to an unrepresented appellant, without instructing her as to exactly what she needs to do with it. A simple statement by the Board that it finds Dr. Shaw’s opinion speculative, and suggesting that appellant forward the report to Dr. Shaw or another expert for rebuttal, would have prevented this violation of appellant’s constitutional rights. The remedy in this case is to remand the case, to ask Dr. Shaw for rebuttal, and to admit the numerous treatises that negate Dr. Persselin’s opinion.
The Gilbert Court (cited by the Board as the basis for its decision) held that, in order to deny benefits, the negative evidence cannot be phrased as “not as likely,” but rather the preponderance of the evidence must be against the claim, i.e., that there is no reasonable possibility that Veteran is correct: The Board was thus faced with two testimonies provided by equally eminent professionals in the VA healthcare system.
Dr. Shaw, Veteran’s treating physician, opined that Rheumatoid Arthritis probably (that is, “with considerable certainty”) began while Veteran was in service. Dr. Persselin opined that there was less than a 50 percent probability that Veteran’s Rheumatoid Arthritis had its initial clinical presentation during service.Dr. Persselin did not state that there is no reasonable possibility Veteran is correct, and thus his testimony does not meet the non-persuasion level required by the rule. These two opinions appear to be in equipoise.
The majority of the official records from 1953 to 1960 have been lost.
The records from Veteran’s private medical providers from 1960-1968 were also lost.
Appellant has repeatedly testified that such records were provided when Veteran initially filed for disability but were lost while in custody of the VA.
The testimony of Veteran and appellant were not provided to the expert.
In February 2008, a VA physician, Dr. Shaw, who is a medical director and who was Veteran’s personal physician for years, provided a medical report basing his opinion on the entire medical record and on his familiarity with Veteran. He opined that, by history, Veteran was diagnosed in 1960 with RA (Rheumatoid Arthritis), but was reported as early as May 1954 to have had back pain diagnosed as “sprained back” during service. Dr. Shaw. opined that Veteran probably (that is, “with substantial certainty”) developed Rheumatoid Arthritis while in service, but noted that there were only very short notations of his Infirmary visits suggesting that this was the case, and no clear trail of evidence. The physician also noted that any tests pointing to a diagnosis of Rheumatoid Arthritis while in service were not performed by the examining physicians, and that such testing would have been rudimentary at best in 1954-56.
Not satisfied with the opinion of Dr. Shaw, the Board sought an advisory medical opinion from the Veterans Health Administration (VHA). The expert, Dr. Persselin, admitted to having no access to crucial information from 1953 to 1986. Unlike Dr. Shaw, Dr. Persselin had never examined Veteran, and thus he could not opine on Veteran’s credibility or on his medical history which had been provided to Dr. Shaw. The expert testimony merely provided an opinion that back pain is “not consistent with any initial presentation of Rheumatoid Arthritis” based on the expert’s limited review of the medical literature. The Board was thus faced with two testimonies provided by equally eminent professionals in the VA healthcare system.
Dr. Shaw, Veteran’s treating physician, opined that Rheumatoid Arthritis probably (that is, “with considerable certainty”) began while Veteran was in service. Dr. Persselin opined that there was less than a 50 percent probability that Veteran’s Rheumatoid Arthritis had its initial clinical presentation during service.Dr. Persselin did not state that there is no reasonable possibility Veteran is correct, and thus his testimony does not meet the non-persuasion level required by the rule. These two opinions are most likely in relative equipoise.
In order to avoid applying the benefit-of-the-doubt doctrine, the Board simply rejected Dr. Shaw’s opinion as speculative and wholly embraced Dr. Persselin’s opinion. We argue that Dr. Shaw’s testimony is not speculative, and that Dr. Persselin’s testimony is inaccurate. Thus a remand is needed to develop the record fully.
The benefit-of-the-doubt doctrine imposes an additional duty on the court. When 4004(d)(1) has been complied with, and when this Court is reviewing Board decisions which do not apply the “benefit-of-the-doubt” standard, it is engaged in two separate analyses. Pursuant to 38 U.S.C. 4061(a)(4), the Court must first determine if the Board’s findings of material fact made in reaching its decision were clearly erroneous. Second, after making these determinations, this Court must use them and apply 38 U.S.C. 4061(a)(1), (3) to decide whether the Board’s decision not to apply the “benefit of the doubt” standard was in accordance with 38 U.S.C. 3007(b). Though these two analyses are interrelated, they are still made independently of one another and under different scopes of review.
Dr. Shaw, Veteran’s treating physician, opined that Rheumatoid Arthritis probably (that is, “with considerable certainty”) began while Veteran was in service. Dr. Persselin opined that there was less than a 50 percent probability that Veteran’s Rheumatoid Arthritis had its initial clinical presentation during service.Dr. Persselin did not state that there is no reasonable possibility Veteran is correct, and thus his testimony does not meet the non-persuasion level required by the rule. These two opinions are most likely in equipoise.
The Board threw out Dr. Shaw’s opinion for no apparent reason and wholeheartedly accepted Dr. Persselin’s opinion. The Board cannot meet its duties to assist by merely sending the report of the expert to an unrepresented appellant, without instructing her exactly as to what she needs to do with it. A simple statement by the Board that it finds Dr. Shaw’s opinion speculative, and suggesting that appellant forward the report to Dr. Shaw. or another expert for rebuttal, would have prevented this violation of appellant’s constitutional rights. The remedy in this case is to remand the case, to ask Dr. Shaw. for rebuttal, and to admit the numerous treatises that negate Dr. Persselin’s opinion.
The Board also acknowledges the contentions of appellant and her former attorney concerning the etiology of Veteran’s contributory cause of death in multiple written statements of record as well as the July 2008 hearing transcript. The record does not show, however, that appellant has the medical expertise that would render competent her statements as to the relationship between Veteran’s military service and Rheumatoid Arthritis.
J Spinal Disord Tech. 2003 Feb;16(1):38-43. Radiologic findings of the lumbar spine in patients with Rheumatoid Arthritis, and a review of pathologic mechanisms.
Kawaguchi Y, Matsuno H, Kanamori M, Ishihara H, Ohmori K, Kimura T.
 The Court should note that the Board denied benefits in the case at bar, because it relied on testimony which suggested that Rheumatoid Arthritis involving the back does not exist.
 “The Board also found the most probative evidence of record to be the April 2009 VHA medical opinion rendered by Dr. Persselin whoconcluded that there was less than a 50 percent probability that Veteran’s Rheumatoid Arthritis had its initial clinical presentation during service or within one year after separation from service.
The Board also found the most probative evidence of record to be the April 2009 VHA medical opinion rendered by Dr. Persselin whoconcluded that there was less than a 50 percent probability that Veteran’s Rheumatoid Arthritis had its initial clinical presentation during service or within one year after separation from service.
The Board found the most probative evidence of record to be the April 2009 VHA medical opinion rendered by Dr. Persselin whoconcluded that there was less than a 50 percent probability that Veteran’s Rheumatoid Arthritis had its initial clinical presentation during service or within one year after separation from service.

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