On appeal from the Department of Veterans Affairs (VA) Regional Office in St. Petersburg, Florida
THE ISSUES
1. Entitlement to service connection for tinnitus.
2. Entitlement to service connection for malaria.
3. Entitlement to service connection for cholelithiasis with
gallstone pancreatitis, status post cholectystectomy and
hepatitis, with cystic ducts lymph node with reactive
hypoplasia.
4. Entitlement to service connection for global hypokinesis
suggestive of cardiomyopathy.
5. Entitlement to service connection for liver damage.
6. Entitlement to service connection for peripheral vascular
disease (PVD).
REPRESENTATION
Appellant represented by: The American Legion
WITNESS AT HEARING ON APPEAL
The Veteran, C. Bash, M.D., and M.S.
ATTORNEY FOR THE BOARD
L. A. Rein, Counsel
INTRODUCTION
The Veteran had active military service from March 1978 to
February 1988.
These matters come to the Board of Veterans' Appeals (Board)
on appeal from a January 2008 rating decision of the
Department of Veterans Affairs (VA) Regional Office (RO) in
St. Petersburg, Florida.
In August 2008, the Veteran testified during a hearing before
RO personnel: a transcript of that hearing is associated with
the claims file.
In April 2009, the Veteran, Dr. Bash, and M.S. testified
during a Board personal hearing before the undersigned Acting
Veterans Law Judge in Washington, D.C.; a transcript of that
hearing is of record. The request to hold the record open
for 60 days following the hearing was granted to allow the
Veteran to obtain and submit additional private medical
opinion evidence. Later in April 2009, the Veteran submitted
a written opinion letter from Dr. Bash along with a waiver of
RO initial consideration, waived the remainder of the 60 day
period, and requested that his case be decided by the Board.
The Board notes that service connection for cystic ducts
lymph node with reactive hypoplasia was an issue listed for
appeal; however, because these are clinical findings, and are
associated with the cholelithiasis disability, they have been
included and considered as part of that disability, rather
than continued as a separate disability on appeal. See
38 C.F.R. § 4.14 (the evaluation of the same manifestation
under different diagnoses is to be avoided).
FINDINGS OF FACT
1. The Veteran experienced acoustic trauma in service;
chronic tinnitus in service; continuous symptoms of tinnitus
since service; and the currently diagnosed tinnitus had been
related by competent evidence to the in-service acoustic
trauma.
2. The Veteran contracted malaria in service while stationed
in the Philippines.
3. The residuals of malaria include cholelithiasis with
gallstone pancreatitis, status post cholectystectomy, and
hepatitis; clinical findings of cystic ducts lymph node with
reactive hypoplasia are associated with this disorder.
4. The residuals of malaria include cardiomyopathy of mildly
dilated left ventricle.
5. The residuals of malaria include PVD.
6. In this Board decision, service connection has been
granted for symptoms claimed as liver damage, so there
remains no question of law or fact to decide on the claim for
service connection for liver damage.
CONCLUSIONS OF LAW
1. The criteria for service connection for tinnitus are met.
38 U.S.C.A. §§ 1131, 1137, 5103, 5103A, 5107 (West 2002 &
Supp. 2008); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2008).
2. The criteria for service connection for malaria are met.
38 U.S.C.A. §§ 1131, 1137, 5103, 5103A, 5107 (West 2002 &
Supp. 2008); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2008).
3. The criteria for service connection for cholelithiasis
with gallstone pancreatitis, status post cholectystectomy and
hepatitis, including findings of cystic ducts lymph node with
reactive hypoplasia, are met. 38 U.S.C.A. §§ 1131, 1137,
5103, 5103A, 5107 (West 2002 & Supp. 2008); 38 C.F.R. §§
3.102, 3.159, 3.303 (2008).
4. The criteria for service connection for cardiomyopathy of
mildly dilated left ventricle are met. 38 U.S.C.A. §§ 1131,
1137, 5103, 5103A, 5107 (West 2002 & Supp. 2008); 38 C.F.R.
§§ 3.102, 3.159, 3.303 (2008).
5. The claim for service connection for liver damage is
moot. 38 U.S.C.A. § 7104 (West 2002 & Supp. 2008); 38 C.F.R.
§ 4.14 (2008).
6. The criteria for service connection for PVD are met. 38
U.S.C.A. §§ 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp.
2008); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2008).
REASONS AND BASES FOR FINDING AND CONCLUSIONI. Duties to Notify and Assist
The Veterans Claims Assistance Act of 2000 (VCAA), codified
at 38 U.S.C.A.
§§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 &
Supp. 2008) includes enhanced duties to notify and assist
claimants for VA benefits. VA regulations implementing the
VCAA have been codified, as amended at 38 C.F.R. §§ 3.102,
3.156(a), 3.159, and 3.326(a) (2008).
Notice requirements under the VCAA essentially require VA to
notify a claimant of any evidence that is necessary to
substantiate the claim, as well as the evidence that VA will
attempt to obtain and which evidence he or she is responsible
for providing. See, e.g., Quartuccio v. Principi, 16 Vet.
App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A.
§ 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in
Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a
substantially complete application for benefits is received,
proper VCAA notice must inform the claimant of any
information and evidence not of record (1) that is necessary
to substantiate the claim; (2) that VA will seek to provide;
and (3) that the claimant is expected to provide. The Board
notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has
been revised, in part. See 73 Fed. Reg. 23,353- 23,356
(April 30, 2008). Notably, the final rule removes the third
sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA
will request that a claimant provide any pertinent evidence
in his or her possession.
VA's notice requirements apply to all five elements of a
service connection claim: Veteran status, existence of a
disability, a connection between the Veteran's service and
the disability, degree of disability, and effective date of
the disability. Dingess/Hartman v. Nicholson, 19 Vet. App.
473 (2006). An October 2007 letter provided such notice.
In this appeal, an October 2007 pre-rating letter provided
notice to the Veteran of the evidence and information needed
to substantiate his claims for service connection on appeal.
This letter also informed the Veteran of what information and
evidence must be submitted by the Veteran, and what
information and evidence would be obtained by VA. The letter
further requested that the Veteran submit any additional
information or evidence in his possession that pertained to
his claims. In addition, the Veteran was provided information
regarding disability ratings and effective dates consistent
with Dingess/Hartman. The February 2008 RO rating decision
reflects the initial adjudication of each of the claims for
service connection on appeal.
Additionally, the record also reflects that VA has made
reasonable efforts to obtain or to assist in obtaining all
relevant records pertinent to the matter on appeal. Pertinent
medical evidence of record includes the Veteran's service
treatment records, private medical records, the report of a
January 2008 VA examination, and private opinion letters from
Dr. Bash dated in July 2008 and in April 2009. Also of record
and considered in connection with the appeal is the
transcript of the August 2008 hearing before RO personnel and
the April 2009 Board hearing, as well as various written
statements provided by the Veteran as well as by his
representative and other service members, on his behalf. In
addition, the Veteran has submitted medical articles as
evidence in support of his claims.
In this case, the Board is granting in full the benefit
sought on appeal. Accordingly, assuming, without deciding,
that any error was committed with respect to either the duty
to notify or the duty to assist, such error was harmless and
will not be further discussed.
II. Service Connection Analysis
Service connection may be granted for disability resulting
from disease or injury incurred in or aggravated during
service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Such a
determination requires a finding of current disability that
is related to an injury or disease in service. Watson v.
Brown, 4 Vet. App. 309 (1993); Rabideau v. Derwinski, 2 Vet.
App. 141, 143 (1992). For the showing of chronic disease in
service, there is required a combination of manifestations
sufficient to identify the disease entity, and sufficient
observation to establish chronicity at the time. If a
condition noted during service is not shown to be chronic,
then generally, a showing of continuity of symptoms after
service is required for service connection. See 38 C.F.R.
§ 3.303(b). Service connection may be granted for a
disability diagnosed after discharge, when all the evidence,
including that pertinent to service, establishes that the
disability is due to disease or injury that was incurred or
aggravated in service. 38 C.F.R. § 3.303(d).
When, after careful consideration of all procurable and
assembled data, a reasonable doubt arises regarding service
origin, the degree of disability, or any other point, such
doubt will be resolved in favor of the claimant. By
reasonable doubt is meant one that exists because an
approximate balance of positive and negative evidence which
does satisfactorily prove or disprove the claim. It is a
substantial doubt and one within the range of probability as
distinguished from pure speculation or remote possibility.
38 C.F.R. § 3.102. See also 38 U.S.C.A. § 5107(b); 38 C.F.R.
§ 3.102.
A. Service Connection for Tinnitus
The Veteran has asserted that he has tinnitus related to in-
service noise exposure, as he has testified to during RO and
Board hearings. The Board points out that the Veteran is
competent to state that he has tinnitus. See Charles v.
Principi, 16 Vet. App. 370 (2002).
Lay assertions may serve to support a claim for service
connection by supporting the occurrence of lay-observable
events or the presence of disability or symptoms of
disability subject to lay observation. 38 U.S.C.A. §
1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492
F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451
F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as
potentially competent to support presence of disability even
where not corroborated by contemporaneous medical evidence).
Here, the Veteran is competent to say that he experienced
noise exposure in service, symptoms of tinnitus while in
service and since service, and still has ringing in his ears.
After a review of all the evidence of record, the Board finds
that the Veteran experienced acoustic trauma in service,
experienced chronic tinnitus in service, and has experienced
continuous symptoms of tinnitus since service. Although STRs
are negative for treatment of tinnitus during service, the
Veteran's DD214 shows that his military occupational
specialty for 7 years and 2 months was a machine gunner. The
Veteran asserts and has credibly testified that he began to
experience tinnitus in 1985, during service, and that his
tinnitus has continued since discharge from service.
During the April 2009 Board hearing, the Veteran testified
that his military occupational specialty for the first three
years of service was as a machine gunner and that he was
exposed to acoustic trauma on an almost daily basis. He
testified that he has never been treated for tinnitus. Dr.
Bash testified during the Board personal hearing that it was
his opinion that the acoustic trauma in service was the most
likely cause of the Veteran's tinnitus.
The Board further finds that the currently diagnosed tinnitus
has been related by competent evidence to the in-service
acoustic trauma. In an April 2009 letter,
Dr. Bash again offered the opinion that the Veteran has
tinnitus related to his service time exposure to loud machine
gun fire. He noted that the Veteran had normal hearing when
he entered service; he was exposed to loud noise in service
according to his occupation code and the Veteran's testimony;
his post-service exposure to noise has been limited in
nature, and the Veteran testified that he only had occasional
loud noise exposure since service. Therefore, Dr. Bash
opined that the Veteran should be service connected for his
tinnitus as the records do not contain another more likely
etiology for this disability. For these reasons, the Board
finds that service connection for tinnitus is warranted.
B. Malaria, cholelithiasis with gallstone pancreatitis,
status post cholectystectomy and hepatitis, cystic ducts
lymph node with reactive hypoplasia, cardiomyopathy, and PVD
Initially, the Board notes that 38 C.F.R. § 4.88b, Diagnostic
Code 6304 provides some guidance in this case. In this
regard, DC 6304 states that the diagnosis of malaria depends
on the identification of the malarial parasites in blood
smears. In the alternative, if the Veteran served in an
endemic area and presents signs and symptoms compatible with
malaria, the diagnosis may be based on clinical grounds
alone. Relapses must be confirmed by the presence of
malarial parasites in blood smears. Thereafter, the
condition may be rated for residuals under the appropriate
system. 38 C.F.R. § 4.88b, Diagnostic Code 6304.
Service treatment records show that in 1982 the Veteran was
hospitalized with a fever of unknown origin. He had
complaints of fever, chills, headaches, night sweats, and
being tired and weak It was noted that the Veteran had
service in the Philippines and Panama. The Veteran reported
that he was exposed to people who had malaria and he suffered
insect bites to the back of his neck while in Panama, which
were infected. The records reflect that the Veteran was
assessed with fever of unknown origin, infections, malarial
hepatitis, and systolic heart murmur 2/6. In December 1982,
he was diagnosed with viral syndrome. Tests came back
negative for malaria. It was noted that the Veteran had a
slightly enlarged and tender liver edge for which a liver and
spleen scan revealed mild hepatomegaly and moderate
splenomegaly. There was no definitive diagnosis of malaria.
The Veteran was assessed with possible hepatitis with
increased enzymes. In December 1982 in service, the Veteran
also received treatment for adenopathy.
Post-service medical records from Holmes Regional Medical
Center, dated from December 1996 to November 2006 show cystic
duct lymph node with reactive hyperplasia due to chronic
inflammation of the gallbladder since 1996. In addition, the
records reflect that the Veteran was clinically indicated
with global hypokinesis suggestive of idiopathic dilated
cardiomyopathy. He was also treated for hepatitis.
A December 1996 Kennestone Regional Healthcare System record
reflects that the Veteran was admitted for complaints of
fever, chills, and dark urine for the past 10 days. He
reported a history of hepatitis in 1985, but his hepatitis
profile was noted as normal. The Veteran gave a history of
malaria in the 1970s. The hospital physician found the
Veteran to have had pancreatitis as well as abnormal liver
tests and jaundice with fever and chills, most likely
cholangitis. He felt that this was all related to
gallbladder disease with possible choledocholithiasis. It
was also noted that the Veteran's had a regular heart rate
and rhythm with a 2/6 systolic murmur at the left sternal
border. A pathology report reflects that a specimen labeled
"gallbladder" was analyzed and the examining pathologist
diagnosed gallbladder (cholecystectomy): chronic hyperplastic
cholecystitis; cystic duct lymph node with reactive
hyperplasia. The hospital discharge diagnosis was acute
gallstone pancreatitis, cholelithiasis, and hepatitis.
Private treatment records from M.C. Moss, MD., dated from
January 2006 to October 2006, reflect that the Veteran was
diagnosed with superficial femoral, popliteal, and
infrapopliteral artery occlusive disease and claudication in
both lower extremities.
In an October 2007 letter, Dr. Moss noted that the Veteran's
idiopathic dilated cardiomyopathy could be secondary to
malaria that the Veteran contracted in service.
A January 2008 VA examination report reflects that the
Veteran was diagnosed with cholelithiasis with gallstone
pancreatitis, status post cholectystectomy and hepatitis,
borderline mildly dilated left ventricle with idiopathic
dilated cardiomyopathy. The VA examiner could not resolve
whether this condition was related to the episode of fever of
unknown origin with adenopathy in service without resorting
to mere speculation. The VA examiner also diagnosed the
Veteran with residuals of cystic duct lymphadenopathy on
biopsy. Again, the VA examiner opined that she could not
resolve whether this condition was related to the episode of
fever of unknown origin with adenopathy in service without
resorting to mere speculation.
In an April 2008 letter, CDR M.L.T., one of the physicians
who treated the Veteran in service, noted that the Veteran
had forwarded pertinent service treatment records for his
clarification. He stated they were concerned about the
possibility of malaria infection and several orders were
written to optimize their chances of making the diagnosis.
Based on the laboratory results available, they were unable
to substantiate the condition. Neither did they confirm a
viral or other definite cause of the illness. The physician
noted that hilar fullness on a chest x-ray and mild ejection
murmur were deemed unrelated. He wrote that lack of
identification of malarial organisms did not eliminate
malaria as a possibility.
In a July 2008 letter, Dr. Bash provided favorable opinions
that he asserted were all to a high degree of medical
certainty (much more likely than not). He noted that he had
reviewed the Veteran's claims file. Dr. Bash also noted that
a medical examination was not needed as such would only tell
him the current extent of the Veteran's disease, which is
already documented in the records. Dr. Bash opined that the
Veteran likely had malaria in service. In support of his
opinion, Dr. Bash noted that the Veteran's STRs showed he had
typical cyclical fevers of 104 degrees, hepatospleenomeglia,
and night sweats, all of which are consistent with malaria.
In addition, the Veteran was not assigned another diagnosis
to account for this entire clinical syndrome. Dr. Bash
refers to at least one negative blood smear in service,
noting that Malaria is very difficult to detect, and that
detectable parasitemia may have been missed. In support of
his opinion that the Veteran did in fact have malaria in
service, Dr. Bash refers to CDR Tobin's letter that they were
concerned that the Veteran had malaria.
Dr. Bash also noted that the Veteran developed a new 2/6
systolic murmur during his in-service hospitalization, which
was not present prior to entry into service. He also stated
that the Veteran now has global hypokinesis. It was his
opinion that the Veteran's new heart murmur in 1982 was the
first sign of his current cardiac disease. He supported his
opinion noting that the Veteran entered duty with a normal
heart, he developed new cardiac problems 2/6 murmur while in
service. His records do not provide a more likely etiology
for his current global hypokinesis. He also opined that the
Veteran's current PVD was made worse by his poorly performing
heart.
In a February 2009 letter, the Veteran's Platoon Commander,
M.S., wrote that in the spring or summer of 1979 the Veteran
contracted malaria and was quite sick. He stated that he
recalled this incident well as he spoke with the Veteran's
doctor by telephone who informed him that the Veteran's
diagnosis was malaria. In addition, they had to take the
Veteran off the normal duty roster and the Veteran was sent
to the naval base's communication station, which was
considered a "quiet duty" station where M.S. thought the
Veteran could complete his recovery.
During the April 2009 Board hearing and in an April 2009
letter, Dr. Bash opined that the Veteran has global
hypokinesis due to his service time experience. He noted the
1982 hospital evaluation showing that the Veteran entered
service with a normal heart but developed a 2/6 murmur during
his hospitalization. He opined that the Veteran had a normal
heart during his entry into service, that the heart murmur
was not congenital and that the Veteran developed heart
problems in service. He further noted that the Veteran has
continued to have a heart murmur on subsequent post-service
medical evaluations and the Veteran's blood pressure was very
abnormal at 156/98 during the January 2008 VA examination.
Dr. Bash further opined that the Veteran likely had malaria,
hepatitis, gallbladder pancreatitis, cystic duct lymph node
hyperplasia, and PVD in service. He found that the majority
of the Veteran's STRs document that he had a working
diagnosis of malaria during service. His follow-up hospital
testing as per ID workup was all negative for monospot,
cocci, histo, PPD, and amebiasis as per the record and the
January 2008 VA examiner's report by Dr. Trespalacios. Dr.
Bash pointed out that the Veteran was assigned to an endemic
area during service. The testimony of Major Shaw documents
that he was told that the Veteran had malaria by hospital
staff and that Major Shaw then put the Veteran on limited
duty. The Veteran's claims file documents that he has had an
enlarged liver and elevated liver enzymes on all examinations
since his 1982 hospital evaluation consistent with hepatitis.
Dr. Bash opined that the most likely cause of the Veteran's
1982 hospital illness was malaria. He also opined that the
Veteran had hepatitis in service and that his service caused
malaria and chronic hepatitis which lead to chronic
inflammation of his gall bladder, cystic duct lymph node
hyperplasia all of which resulted in his need for gall
bladder surgery. Dr. Bash lastly opined that the Veteran's
PVD is likely due to a vascular response to malaria, which
has been aggravated by his low cardiac output of 35 to 40
percent (EF), as his records do not support another more
likely etiology for his PVD. Dr. Bash concluded that Dr.
Trespalacio's comments in the January 2008 VA examination
report about mere speculation were not well supported by her
opinion as she did not consider the benefit of the doubt
concept nor did she assign a more likely disease to account
for the Veteran's illnesses in service other than the
diagnosis at the time of malaria.
The Board finds the testimony and written opinion by Dr. Bash
to be competent and credible evidence that the Veteran had
Malaria in service that resulted in cholelithiasis with
gallstone pancreatitis, status post cholectystectomy and
hepatitis, cystic ducts lymph node with reactive hypoplasia,
cardiomyopathy, and PVD. See Guerrieri v. Brown, 4 Vet. App.
467, 470-71 (1993) (the probative value of a medical opinion
is based on the medical expert's personal examination of the
patient, knowledge and skill in analyzing the data, and
medical conclusion). The Board notes that Dr. Bash reviewed
the claims file, examined the Veteran prior to rendering his
opinions, and stated the bases for the opinions provided.
Significantly, Dr. Bash's opinions are not contradicted by
any other medical evidence or opinion. The Board notes that
the January 2008 VA examiner could not provide a nexus
opinion regarding these disabilities without resorting to
mere speculation, which the Board finds is of little
probative value. See Hayes v. Brown, 5 Vet. App. 60, 69-70
(1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93
(1992)). Dr. Bash has provided opinion testimony and
statements that are definitive and supported by the evidence
of record. The Board also emphasizes that VA adjudicators
are not free to ignore or disregard the medical conclusions
of VA medical professionals, and are not permitted to
substitute their own judgment on a medical matter. See
Colvin v. Derwinski, 1 Vet. App. 171 (1991); Willis v.
Derwinski, 1 Vet. App. 66 (1991).
Accordingly, the Board finds that service connection for
malaria is warranted. The competent evidence also shows that
the Veteran has various complications that have been related
by competent evidence to malaria, namely, cholelithiasis with
gallstone pancreatitis, status post cholectystectomy and
hepatitis, including findings of cystic ducts lymph node with
reactive hypoplasia, cardiomyopathy, and PVD. The Board
notes that service connection for cystic ducts lymph node
with reactive hypoplasia was an issue listed for appeal;
however, because these are clinical findings, and are
associated with the cholelithiasis disability, they have been
considered as part of that disability and have been included
as part of that disability, rather than continued as a
separate disability on appeal. For these reasons, service
connection is warranted for these disabilities as
complications of malaria.
C. Service Connection for Liver Damage
As discussed in detail above, the Veteran has been granted
service connection for malaria and disabilities resulting
from malaria in service. These actions are consistent with
the criteria for rating Malaria, under Diagnostic Code 6304.
These conditions include specific diagnoses pertaining to
liver damage, i.e., cholelithiasis with gallstone
pancreatitis, status post cholectystectomy and hepatitis, and
findings of cystic ducts lymph node with reactive hypoplasia.
The Veteran has not identified, nor does the competent
evidence reflect, additional symptoms or disorders resulting
from malaria, to include additional residuals of liver damage
that are not already considered in the now service-connected
disabilities.
Except as otherwise provided in the rating schedule, all
disabilities, including those arising from a single entity,
are to be rated separately, and then all ratings are to be
combined pursuant to 38 C.F.R. § 4.25. One exception to this
general rule, however, is the anti-pyramiding provision of 38
C.F.R. § 4.14, which states that evaluation of the "same
disability" or the "same manifestation" under various
diagnoses is to be avoided.
In Esteban v. Brown, 6 Vet. App. 259 (1994), the United
States Court of Appeals for Veterans Claims (Court) held that
the described conditions in that case warranted 10 percent
evaluations under three separate diagnostic codes, none of
which had a rating criterion the same as another. The Court
held that the conditions were to be rated separately under 38
C.F.R. § 4.25, unless they constituted the "same disability"
or the "same manifestation" under 38 C.F.R. § 4.14. Esteban,
at 261. The critical element cited was "that none of the
symptomatology for any one of those three conditions [was]
duplicative of or overlapping with the symptomatology of the
other two conditions." Id. at 262.
In this case, liver damage is part of the grant of service
connection for residuals of malaria that include hepatitis.
As such, liver damage does not constitute a separate
disability, and cannot also be rated under a different
diagnostic code. See 38 C.F.R.
§ 4.14. There remains no question of law or fact to decide
on the claim for service connection for liver damage. For
these reasons, the Board finds that the claim for service
connection for liver damage is moot. 38 U.S.C.A. § 7104; 38
C.F.R. § 4.14.
ORDER
Service connection for tinnitus is granted.
Service connection for malaria is granted.
Service connection for cholelithiasis with gallstone
pancreatitis, status post cholectystectomy, hepatitis,
including findings of cystic ducts lymph node with reactive
hypoplasia, is granted.
Service connection for cardiomyopathy of mildly dilated left
ventricle is granted.
The appeal for service connection for liver damage, having
been rendered moot, is denied.
Service connection for peripheral vascular disease (PVD) is
granted.
J. Parker
Acting Veterans Law Judge, Board of Veterans' Appeals
