Citation Nr: 0205175 Decision Date: 05/24/02 Archive Date: 06/03/02 DOCKET NO. 93-00 412 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for Lyme disease. 2. Entitlement to service connection for headaches, Bell's palsy, a psychiatric disability, and arthritis as secondary to Lyme disease. REPRESENTATION Appellant represented by: Mark R. Lippman, Attorney at Law WITNESSES AT HEARING ON APPEAL Appellant and his sister ATTORNEY FOR THE BOARD Carole R. Kammel, Counsel INTRODUCTION The appellant served on active duty for training from May to August 1982 and from July 20, 1985 to August 3, 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 1991 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In a June 1997 decision, the Board denied the appellant's claims related to Lyme Disease on the basis that the determination of Lyme disease was not confirmed until several years after active duty for training and was not associated with any incident therein. The appellant appealed to the United States Court of Appeals for Veterans Claims (Court). In April 1999, the Court granted a Joint Motion to Remand and Suspend Further Proceedings (Joint Motion). In the Joint Motion, the court vacated the Board's previous decision and remanded the case to the Board to address conflicting evidence and to provide adequate reasons and bases. The Board remanded the case to the RO in August 1999, for further development to include an additional VA examination. In March 2000, a VA Infectious Disease examination was performed. In November 2000, the Board granted the appellant's October 30, 2000 motion for extension of time for 45 days. Additional evidence was received at the Board on December 14, 2000. However, appellant did not waive consideration of this evidence by the RO. As a result, the Board remanded the appellant's claims to the RO in order to provide them an opportunity to review the newly submitted evidence. In response, the RO prepared Supplemental Statements of the Case (SSOC), dated in October and November 2001. The case has been returned to the Board and is ready for final appellate review. FINDINGS OF FACT 1. Lyme disease was not confirmed until several years after the appellant's active duty for training and is not associated with any incident in service. 2. There is no service-connected Lyme disease disability to which current complaints, to include headaches, Bell's palsy, a psychiatric disorder, and arthritis, may be attributed. CONCLUSIONS OF LAW 1. Lyme disease was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1131, 5103A, 5107 (West 1991 & Supp. 2001); 38 C.F.R. § 3.303(b) (2001). 2. As service connection is denied for Lyme disease, headaches, Bell's palsy, a psychiatric disorder, and arthritis, may not be considered secondary thereto for service connection purposes. 38 U.S.C.A. §§ 1131, 5103A, 5107 (West 1991 & Supp. 2001); 38 C.F.R. § 3.310 (2001). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As a preliminary matter, the Board notes that effective November 9, 2000, the Veterans Claims Assistance Act of 2000 was signed into law. See Pub. L. No. 106-475, 114 Stat. 2096 (2000) (VCAA). This law sets forth requirements for assisting a claimant in developing the facts pertinent to his claims. Although this law was enacted during the pendency of this appeal, the Board finds that there has been no prejudice to the appellant in this appeal. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that the RO has notified the appellant of the evidence need to substantiate his claims as set forth in numerous Statements of the Case and Supplemental Statements of the Case (SSOC) during the duration of the appeal. Most recently, in SSOCs, dated in October and November 2001, the appellant was informed of the notice and duty to assist provisions of the VCAA. In addition, the appellant gave testimony concerning his claims at a May 1992 hearing at the RO in Roanoke, Virginia. The appellant was provided a recent VA infectious disease examination with regard to his claims in March 2000. Finally, in a statement submitted by the appellant's attorney to the RO, dated in November 2001, he indicated that the appellant did not have any additional evidence to submit in support of his claims and he requested that the case be forwarded to the Board for final appellate review. In short, the Board concludes that the duty to assist has been satisfied, as well as the duty to notify the appellant of the evidence needed to substantiate his claims. The Board will proceed with appellate disposition on the merits. VA issued regulations to implement the VCAA in August 2001. 66 Fed. Reg. 45,620 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a)). The amendments were effective November 9, 2000, except for the amendment to 38 C.F.R. § 3.156(a) which is effective August 29, 2001. Except for the amendment to 38 C.F.R. § 3.156(a), the second sentence of 38 C.F.R. § 3.159(c), and 38 C.F.R. § 3.159(c)(4)(iii), VA stated that "the provisions of this rule merely implement the VCAA and do not provide any rights other than those provided in the VCAA." 66 Fed. Reg. 45,629. Accordingly, in general where the record demonstrates that the statutory mandates have been satisfied, the regulatory provisions likewise are satisfied. I. Factual Background The appellant contends that he suffers from Lyme disease as a result of tick bites received during the two week period of active duty for training which began in July 1985. Service medical records includes a copy of an Individual Sick Slip, DD Form #689, dated July 22, 1985. In the section for the Unit Commander's remarks are two entries, which were written by two different individuals. One entry is as follows: "knee left Injured." Below this entry is the following: "Insect bite's Rash!" Significant in the section for the Medical Officer's remarks, no mention of an insect bite was made. It is also unclear why an exclamation mark was used to describe the "Insect bite's rash" and not the left knee injury. A May 1986 Report of Medical History, reflects that the appellant reported being in good health. He indicated that he had swollen or painful joints. Private and VA medical records, dating from 1989-1990, reflect that when examined by a private physician in May 1989, the appellant complained of a rash after returning from the Bahamas four days previously. It was noted that just before he had departed, he had broken out in a rash. A diagnostic impression of possible contact dermatitis versus insect bite was entered at that time. A February 1990 report of private examination reflects that the appellant had "no major concerns" and the examiner found no difficulties. When seen in March 1990, the appellant indicated that he was concerned of a tick bite reaction that he had one and one half years ago while stationed at Fort McCoy. The appellant stated that he was seen by a Reserve physician but that he did not remember what was done. Lyme disease serology tests, performed in March 1990, revealed minimally elevated serum Lyme titers. A handwritten annotation showed, "Tick Bite: ~ 2 yrs ago. Shot?" A dermatology biopsy follow up report, performed in April 1990, revealed a diagnosis of blue nevus, not related to an arthropod reaction or Lyme disease. When seen by a private physician in April 1990, the appellant related that he had been bit by a tick two years previously and, as a result, he had developed a rash which started out as a small dot, grew over the lower portions of his leg and had a raised border with a central area being cleared. Since that time, the appellant reported having palpitations and sudden arthralgias and myalgias. The physician related that he felt compelled to treat the appellant for stage three Lyme disease. The appellant was placed on medication. An assessment of Lyme disease, stable three was recorded at that time. In an undated report from a private physician to the Wisconsin State Epidemiologist of the Wisconsin Division of Health, it was reported that the appellant had arthralgia/myalgia which began in 1988, and that a tick bite occurred in 1988, a month prior to illness. Private hospitalization reports, dated in September 1990, reflect that the appellant presented to the emergency room with complaints of acute onset of right eye pain, weakness and paresthesias on the right side of his face. A diagnosis of Bell's palsy was recorded. He was admitted to the hospital with Bell's palsy and Stage III Lyme disease with a question of neurologic involvement. A private infectious disease consultation report, dated September 17, 1990, reflects that the appellant gave a history that he was at Camp McCoy in 1985, that he had sustained deer tick bites, especially in the lateralmalleolar area, and that he had developed an acute rash in a ring on his right calf. The appellant reported having felt ill with a fever, malaise, and achiness for two weeks which settled down into a pattern of chronic and recurrent arthralgias, off and on palpitations, memory losses, disorientation, and behavior changes. The examiner noted that the appellant had come to the emergency room a couple days previously after he had developed acute right facial palsy. An impression of acute Bell's palsy, which lasted 72 hours, which was ascribed to Lyme disease but apparently five years after the alleged contracting of the bacteria was recorded. The examiner expounded that it was certainly possible that the appellant had been re-exposed within the last month or two, which was more consistent with the usual pattern of Bell's palsy occurring as a stage 2 manifestation of Lyme disease within the first few months of illness. However, the examiner noted that it was not impossible for Bell's palsy to have developed years later. A discharge summary, dated September 19, 1990, reflects that the physician had first diagnosed the appellant with Lyme disease in April 1990, after his history showed a tick bite in 1985 and a bull's-eye lesion. At discharge, diagnosis of stage 3 Lyme disease and Bell's palsy were recorded by the examiner. An October 1990 VA Infectious Disease Examination report is also of record. After examination, examiner entered an impression that the appellant was "certainly consistent" with stage 3 Lyme disease, although the findings were not "pathognomic." The VA examiner also stated that the appellant had "probably" been exposed to a tick bite at Fort McCoy in 1985 and that the sequelae that he experienced "may indeed be related to Lyme's disease." Diagnoses of adjustment disorder and headaches were also recorded at that time. A copy of an "Acute and Communicable Disease Case Report," dated September 18, 1990, reflects that the appellant's Lyme disease symptoms began in 1988. DA Form 2173, dated in September 1990, reported that the appellant had been taken to the medical clinic for an insect bites rash, was given medication and was released. It was noted that the appellant had received treatment by a private physician in September 1990 and was treated for "step" 3 Lyme disease, which the appellant claimed to have resulted from the insect bite. An October 1990 handwritten note, submitted by an Army Community Hospital in Fort Leonard Wood, Missouri, reflects that there was no documentation in the medical record that the appellant sustained any insect bites during the period in question (July 1985), and that there was no way to provide or disprove whether he incurred this illness as a result of a bite in 1985 or not. A January 1991 private rheumatology consultation report reflects that the appellant reported a history of having Lyme disease dating back to his active duty for training at Fort McCoy consistent with that previously reported in this decision. The examiner recommended that the appellant should have had permanently positive blood serologic test for Lyme disease, since the supposed tick bite occurred in 1985 which was followed by a rash and flu-like symptoms but which was never treated with antibiotics until almost five years later. The examiner noted that it was conceivable that the episode in service was not Lyme disease. The examiner recommended that reliable lab testing be performed, and if they were negative, prior positive Lyme serologies would be false- positives. The examiner finally related that if the appellant was re-exposed to Lyme disease within the previous year and just converted with the bell's Palsy, his serologic test should remain positive and not disappear altogether if, indeed, his Bell's Palsy was related to the Lyme disease. Statements submitted by individuals who served with the appellant during his period of active duty for training, received by the RO in January 1992, reflect that they recalled removing ticks from the appellant's legs in 1985. A report entitled, Lyme Disease: A Clinician's Guide, dated in January 1989, received by the RO in January 1992, discussed current information about the types of Lyme disease, the symptoms, such as a bull's eye rash, fly-like symptoms, headaches, Bell's palsy, and swollen knees associated with each type and the time of onset of symptoms after disease onset. Statements, submitted by the appellant's friends, family and co-workers, dated in March and April 1992, include references to the appellants current complaints, especially his mental status. Private medical reports, dating from January to April 1992, reflect that the appellant reported having side effects of his Lyme disease, such as depression and headaches. A March 1992 report reflects that the appellant had Lyme disease in 1985 and was diagnosed in 1990. During a May 1992 hearing at the RO in Roanoke, Virginia, the appellant testified that while he was on active duty for training, he had several ticks removed from both of his legs, that he developed a rash on the right leg, that he received an ointment for the rash, and that he had other symptoms such as swelling in the knees. He related that he was hospitalized in 1990 with Bell's palsy. The appellant testified that he went to the Bahamas in 1989 and when he returned, he had a rash on his arm. He indicated that he was receiving treatment for a nervous disorder and arthritis. The appellant indicated that he took medicine for headaches. He testified that he was first treated for Lyme disease in 1990. He clarified that he was only at Fort McCoy in 1985. The appellant's sister indicated that before 1985, the appellant was a happy person, and that she became aware of his illness in approximately 1989. In October 1994, the Board determined that on the basis of the evidence of record it was unclear if the appellant's disability could be reasonably associated with a tick bite during a period of active duty for training in July 1985. The claims were therefore remanded to the RO in Roanoke, Virginia for additional development, to include an opinion concerning the relationship if any between a tick bite in July 1985 and the appellant's current disabilities. Records received subsequent to the Board's October 1994 remand request included additional private treatment records, dating from 1990-1993, which revealed treatment for various disabilities, to include psychiatric complaints. On June 21, 1996, an opinion was provided by a VA infectious diseases specialist. His report is as follows: I was asked to review the claimant's medical record. I found there to be no evidence of an exanthem of Lyme disease or clinical evidence of Lyme disease during or within a clinically relevant period of time after the claimant's July 20-Aug. 3, 1985[,] active duty military service at Camp McCoy. In 1990, only eruptions of "blue nevus" and "veruca vulgaris" were seen by physician's even though the patient gave a history of a "bull's eye" exanthem (which would have been compatible with acute Lyme disease if it had been present). The acute, first stage of Lyme disease -- the bull's eye exanthem -- could not have developed as a result of an exposure to Lyme Borrelia - carrying - ticks five years earlier; the incubation period of Lyme disease is measured in a few days to a couple of weeks or a little longer rather than years. In later years, after 1990, the symptoms of depression and perhaps other psychiatric illness predominated in this patient's case -- suggesting some diagnosis other than Lyme disease. Spinal fluid titers were negative for Lyme disease. The minimally elevated serum Lyme titers in 1990 were too low to be diagnostic of disease. Although Bell's palsy can be a feature of a later stage of Lyme disease, it is highly unlikely that this patient's Bell's palsy was due to a 1985 episode of Lyme disease since there was no evidence of Lyme disease in 1985 in this patient. Thus I find no evidence of Lyme disease resulting from the military service. In November 1996, the RO received copies of excerpts from articles entitled, "Protect Yourself from Lyme Disease" and "Lyme Disease the Great Imitator" which discussed the signs and symptoms of Lyme disease, and treatment and preventive measures regarding Lyme disease. The latter article also described Wisconsin and the whole upper Midwest as an area where the disease was clustered. A letter, submitted by P.K., dated in June 1997, reflects that he had served with the appellant during annual training in 1985 at Fort McCoy, and that he remembered the appellant having a rash with two circles around it on his thigh. A news article entitled, "Antibiotics cannot treat all tick- borne disease," by Dr. Peter Gott, discussed the symptoms and methods of treatment for Lyme disease. A November 1997 report, submitted by Amar J. Singh, M.D., reflects that he had treated the appellant for severe depression, psychomotor retardation with psychotic features which he believed were due to Lyme disease, which were known to cause cognitive impairment, psychosis and depression in patients. Copies of a booklet entitled, "Lyme Disease the Cause, the Cure, the Controversy," were received by the RO in October 1999, and provided information on the prevention, diagnosis, and treatment for Lyme disease. Private medical reports, dating from 1997-1999, reflect that in December 1998, the appellant was diagnosed with residual Bell's palsy on the right side, which might or might not be related to Lyme disease. It was also indicated that the appellant had mild right sided facial weakness with occasional fasciculations and facial myokymia. In February 1999, the appellant was diagnosed as having a history of Lyme disease with no evidence of any current activity. A lab report, dated in September 1999, indicated that the result of Western Blot showed the Lyme Wegener's granulomatosis, immunoglobulin G, was negative while the Lyme Western Blot, immunoglobulin M was positive. Other medical reports, dated in September and October 1999, noted a diagnosis of "no evidence of active disease." The appellant was provided a VA infectious disease examination in March 2000. A review of the report reflects that the examiner had reviewed the entire claims file, and reported the appellant's history consistent with that previously reported in this decision. After a physical examination of the appellant, the examiner entered a diagnosis of myalgias and arthralgias. The examiner noted that the appellant's history and physical examination was suggestive of a diagnosis of Lyme disease. However, he further reported that the onset of the appellant's Lyme disease was September 1990 given the history of presentation of Bell's palsy and subjective complaints of myalgias and arthralgias. The examiner noted that the appellant's complaints of back and knee pain began in 1980 and 1981, with a January 1981 visit, which was secondary to a motor vehicle accident in 1985. The examiner indicated that there was a history of a bite in 1985 as related by the patient, and possibly by a notation in the chart, but that there was a question of authenticity due to two different handwritings. The VA examiner in March 2000 concluded that it was impossible to state that the bites in 1985 caused the appellant's Lyme disease because of the following reasons: (1) the appellant resided in Wisconsin and could have been exposed to tick bites at other times; (2) the titers that were obtained for Lyme disease occurred in 1990, which were marginally abnormal, could have been explained by a recent vaccination one month immunization in February 1990; (3) the appellant's admission for Bell's Palsy in September 1990, which usually occurred several months after acquiring a bite with a tick that carried the Borrelia burgdorferi, and not five years out from exposure. Overall, the examiner concluded that it was impossible to state that the appellant had Lyme disease in 1985 regardless of the inability to test for it at that time. In reaching that conclusion, the examiner reiterated that the fact that there is a lack of documentation of symptoms from 1985 to 1990 and that without such objective evidence of symptoms or signs after the tick bite prior to his presentation in 1990, it was difficult to attribute his 1990 and subsequent problems to the tick bites in 1985. Diagnoses of headaches, of a type that is abnormal for Lyme disease, and depression were also recorded by the examiner. A report entitled, Pest Management Study, Lyme Disease Risk Assessment, Fort McCoy, Wisconsin, was received by the RO in September 2000. The report indicated there was a lack of well-defined case recognition and reporting system for Lyme disease before 1985. The report indicated that a formal Lyme disease program had been established with the Occupational Health Nurse (OHN) charged with the responsibility of maintaining an updated records of Lyme disease cases acquired at Fort McCoy. The report recommended a standardized method for data collection and for reporting all cases of Lyme disease, civilian and military, which occurred or were acquired at Fort McCoy. The report further related that the OHN had records of nearly 400 patients who had reported to the medical clinic for tick bites over the period from May to August 1985, that serum was obtained from 313 patients, and that the sera were accidentally thawed for an undetermined period which rendered them useless. A medical report, submitted by Craig N. Bash, M.D., specialist in neuro-radiology, was received by the RO in November 2000. Dr. Bash related that he had reviewed the service medical records and post-service inpatient and outpatient treatment records, X-ray records, appellant's testimony, a letter by the June 1996 VA examiner, examination report of "5/22/2000," and medical literature. Dr. Bash criticized the opinion of the June 1996 VA examiner, who had opined that the appellant's Lyme disease was not the result of a 1985 insect bite. In reaching his opinion, Dr. Bash concluded that the appellant's Lyme disease was caused by his inservice insect bite because the appellant was in a known endemic area, had documented tick bites, had a rash (Bull's eye), which was typical for Lyme disease, had an acute illness consistent with the early stages of Lyme disease, had confirmatory positive high Lyme disease, had been diagnosed and treated for Lyme disease, and had chronic complaints, which were not inconsistent with the chronic stages of Lyme disease. Dr. Bash listed several references at the end of the report. In May 2001, the RO received a letter from the OHN supervisor at Fort McCoy. In the letter, it was indicated that if the appellant had sought care at Fort McCoy, an annotation would have been made in his medical record on his SF 600 in addition to the sick slip, but that copies would not be kept there. Furthermore, if a tick had been removed, this fact would have been annotated on form SF 600. The OHN supervisor further expounded that she was unsure of the protocol in place during 1985, but based on current procedure, the protocol would be to remove the tick, send the tick to "CHPPM" for analysis, and treat the appellant according to the results. She noted that if a tick had been removed, the sick slip would have suggested follow-up care. Finally, the supervisor related that it was very unlikely that the protocol in effect in 1985, sick slip documentation, and completion of the information on SF 600 would have been missed. II. Analysis Service connection connotes many factors, but basically, it means that the facts, as shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces or, if pre-existing such service, was aggravated therein. 38 U.S.C.A. § 1131. Such a determination requires a finding of a current disability which is related to an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 141, 143 (1992). For a 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, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact chronicity in service is not adequately supported, a then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2001). (i) Lyme Disease After a longitudinal review of the evidence of record, the Board finds that the preponderance of the evidence is against an award of entitlement to service connection for Lyme disease. In reaching this conclusion, the Board first disputes the veracity of the evidence with respect to whether or not the appellant received a tick bite during his active duty for training at Fort McCoy in 1985. In this regard, the appellant's DD Form 689, sick slip, reflects that he had an insect bite, which was written in a different handwriting than the other notations listed on the slip. Given the circumstances, the contemporaneous authenticity of that notation is highly suspect. Regardless, the supervisor at OHN specifically indicated that if the appellant did seek care for a tick bite at Fort McCoy during the period from May to August 1985, it would have been highly unlikely that treatment of an embedded tick would have been missed in the protocol, on the sick slip documentation and on the SF 600. Regarding the veracity of the sick slip and the authenticity of the insect bite notation including as standing for the receipt of a tick bite specifically, the supervisor related that if the provider did remove a tick on that date, follow- up would have been noted in the Remarks section of the report. As noted previously in this decision, there are no other findings or references in the appellant's service medical records with respect to a tick bite, Lyme disease or any of the claimed symptoms. However, even assuming that the appellant might have sustained a tick bite during his period of active duty for training in 1985, the clinical evidence does not indicate that any symptoms of Lyme disease, which did not develop until 1990, years after the alleged exposure, were etiologically related to the inservice bite. In support of this conclusion, the Board observes that intervening examinations and treatment reports do not reflect any findings, complaints or history of Lyme disease. In this regard, when examined by a private physician in May 1989, there was no evidence of Lyme disease or any of the claimed symptoms. Indeed, the appellant specifically denied having any headaches, neurological problems, psychiatric symptomatology, or skin disease. He related that he was in good health. It is noted that when the appellant was hospitalized for acute Bell's Palsy in September 1990, he gave history of having had a bull's-eye lesion in 1985. In contrast, however, both the VA examiners, who had examined the appellant in June 1996 and March 2000, unequivocally concluded that without objective evidence of symptoms or signs between the alleged tick bite in 1985 and 1990, it was highly unlikely that the symptoms in 1990 and subsequent problems were due to a 1985 alleged tick bite and bull's eye legion. Significantly, the VA examiners in question were specialists in infectious diseases; they had reviewed the entire claims files, recorded a complete chronology of the appellant's symptoms, and had physically examined the appellant. The essential rationale for both of the VA examiners' opinions was that the incubation period of Lyme disease was measured in a few days to a couple of weeks rather than years. In addition, the VA examiner in March 2000 specifically indicated that at the time of the alleged tick bite in 1985, the appellant had resided in Wisconsin and therefore could have been exposed to tick bites at other times. In support of the VA examiner's opinion, the Board would point to the article entitled, Lyme Disease The Great Imitator, which discussed that Wisconsin, the region in which the appellant lived, and the entire upper Midwest was described as an area where Lyme disease was clustered. Thus, the appellant could have been exposed to a tick bite at another time outside his two week period of active duty for training. The VA examiner in March 2000 also discussed the appellant's minimally elevated serum Lyme titers in 1990, and concluded that they could have been the result of a vaccination one month previously. The examiner noted the notorious inaccuracies of Lyme serology in 1985. Notwithstanding, he concluded that irrespective of the unreliability of testing procedures for Lyme disease at that time, without objective evidence of symptoms or signs after the alleged tick bite prior to the appellant's presentation in 1990, it was difficult to attribute his 1990 and subsequent problems to the 1985 tick bite. These VA examination reports, prepared by physicians trained in the diagnosis and treatment of infectious diseases, have very high probative value. In contrast to the June 1996 and March 2000 VA opinions concluding that the appellant's Lyme disease and resulting symptoms in 1990 were not the result of an alleged tick bite during active duty for training in 1985, Craig N. Bash, M.D., specifically concluded the converse, that the Lyme disease was the result of an inservice tick bite. However, Dr. Bash is not a specialist in infectious disease, did not physically examine the appellant prior to rendering his opinion, and apparently did not review the March 2000 VA infectious disease examination report. More importantly, in contrast to the June 1996 and March 2000 VA examiners, Dr. Bash did not provide an incubation period for Lyme disease. In addition, he indicated that the appellant had clearly documented tick bites per his sick slip in service, which, as noted previously, is open to question, both in terms of its veracity and exactitude. In any event, the term "clearly documented tick bites," is an ill-founded conclusory statement. In addition, two of the reasons given by Dr. Bash for concluding that the appellant's Lyme disease was caused by his inservice insect bite was that the appellant had had a rash (bull's eye) and that he had lived in an area known for tick bites. As noted previously, the appellant only reported having a history of a bull's eye rash; this symptom was not objectively documented on any private or VA clinical evaluation. With regards to the appellant living in an area known for tick bites, as indicated by the VA examiner in March 2000, Wisconsin, the state in which the appellant resided from 1985-1989, was known as an endemic area for Lyme disease. Thus, Dr. Bash failed to discuss alternative possibilities for the origin of the appellant's Lyme disease. Dr. Bash's opinion is thus given little probative value. The Board must find that based upon an overview of the entire record, including the aforementioned opinions, the clear preponderance of the evidence of record is against the appellant's claim of entitlement to service connection for Lyme disease. While the appellant has testified that his current Lyme disease is a result of a tick bite during active duty for training in 1985 at Fort McCoy and he has submitted statements from fellow servicemen to the effect that they had pulled ticks off of the appellant's legs during active duty for training, they are not shown to be qualified to render a medical diagnosis or opinion. Hence, the appellant's and his fellow servicemen's views as to the etiology of the Lyme disease are specifically outweighed by the medical evidence of record cited above. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The appellant has submitted a number of medical articles and treatise material describing Lyme disease, including its diagnosis and treatment. Although this evidence is pertinent, in that it provides information regarding the disability under scrutiny, its probative value is far outweighed by the medical opinions offered by the VA physicians skilled in the treatment and diagnoses of infectious diseases. In explanation, these physicians considered the specific case at hand, namely the etiology of the appellant's Lyme disease versus posed case histories and hypotheticals considered in the medical treatises. The VA physicians had the benefit of a review of the appellant's specific medical record as well as the actual examination of the appellant. The relative value of the treatises in question is speculative at best in contrast to the medical records that concerned the actual case at hand, namely, the appellant's Lyme disease. In any event, the opinions arrived at by the VA specialists are not necessarily inconsistent with the information contained in the treatises in question, in fact, in most instances, the treatises are neutral on the subject of whether the appellant's Lyme disease had its origin in service. Specific note is also taken of the argument posed by the appellant's attorney's that the correspondence requesting pertinent medical opinions from the RO to the OHN was improperly suggestive and that it violated the Court's holding in Coyalong v. West, 12 Vet. App. 524, 534-35 (1999) (holding that questions that the RO presented to an orthopedic specialist in a memorandum violated fairness regulations insofar as they requested that the specialist refute the opinion of the appellant's private physician, and limited the inquiry to two narrow issues). However, a review of the RO's correspondence to OHN, dated in April 2001, reflects that the RO actually asked the OHN to corroborate the appellant's claim as to presence of a tick bite during his active duty for training in 1985. Indeed, the OHN was specifically requested to send any information that was in its possession which might verify the appellant's claim, and if no records were available, this was to be indicated. The fact that the RO requested evidence which might either support or refute the appellant's claims does not violate the Court's holding in Coyalong, which prohibited framing questions which might suggest an answer or limit the field of inquiry by the expert. (ii) Entitlement to Service Connection for Headaches, Bell's Palsy, a Psychiatric Disorder, and Arthritis, as Secondary to Lyme Disease The evidence of record does not show that the appellant had headaches, Bell's palsy, a psychiatric disorder, and/or arthritis in service, or that they were directly associated with his period of service, nor does the appellant argue otherwise. The appellant and his attorney assert, in essence, that the appellant's headaches, Bell's palsy, a psychiatric disorder, and arthritis are a result of and are secondary to his Lyme disease. Under the applicable criteria, disability which is proximately due to or the result of a service-connected disease or injury shall be service-connected 38 C.F.R. § 3.310 (2001). It is on this basis that the appellant is seeking service connection. In a case such as this one, where the regulation and not the evidence is dispositive, the claim must be terminated because of the absence of legal merit or the lack of entitlement under the law. Sabonis v. Brown, 6 Vet. App. 426 (1994). Since service connection cannot be established for Lyme disease based upon the evidence of record, and since the appellant seeks service connection for headaches, Bell's palsy, a psychiatric disorder, and arthritis, secondary to Lyme disease, there is no basis to grant secondary service connection for those disorders. ORDER Entitlement to service connection for Lyme disease is denied. Entitlement to service connection for headaches, Bell's palsy, a psychiatric disorder, and arthritis, secondary to Lyme disease is denied. MICHAEL A. PAPPAS Acting Member, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.