Citation Nr: 0813601 Decision Date: 04/24/08 Archive Date: 05/01/08 DOCKET NO. 03-28 274 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for Isaac's syndrome, as secondary to residuals of service-connected post-operative small bowel obstruction. 2. Entitlement to service connection for fibromyalgia, as secondary to residuals of service-connected post-operative small bowel obstruction. 3. Entitlement to compensation benefits under 38 U.S.C.A. § 1151 (West 2002) for Isaac's syndrome. 4. Entitlement to compensation benefits under 38 U.S.C.A. § 1151 (West 2002) for fibromyalgia. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Johnson, Associate Counsel INTRODUCTION The appellant had active military service from August 1971 to August 1975. This appeal comes before the Board of Veterans' Appeals (Board) from a March 2003 rating decision by the Department of Veterans Affairs (VA) Huntington, West Virginia, Regional Office (RO), wherein the RO denied the veteran's claims for service connection for Isaac's syndrome and for fibromyalgia, both claimed as secondary to medication provided for service- connected postoperative small bowel obstruction. The veteran testified before a Decision Review Officer (DRO) at an RO hearing in March 2004. A transcript of the hearing is of record. During the hearing, the veteran asserted that he was also entitled to compensation benefits under 38 U.S.C.A. § 1151 for the Isaac's syndrome and fibromyalgia, based on the fact that the conditions were due to medication improperly prescribed by VA. (See pages 12-13, March 2004 RO hearing transcript). The issues have been modified as needed. The veteran was scheduled to testify before a Veterans Law Judge at a video-conference hearing in September 2005, but failed to report. He has not indicated that he wishes to have another hearing, nor has he provided a good cause reason for his failure to report. This case was previously before the Board and remanded in a February 2007 Board decision, for further development. The requested development has since been completed. FINDINGS OF FACT 1. The persuasive medical evidence demonstrates that the veteran does not currently have confirmed diagnoses of Isaac's syndrome and fibromyalgia. 2. The currently manifested symptomatology, claimed as Isaac's syndrome and fibromyalgia, was not present in service and is not shown to be related to service; nor is it proximately due to or the result of the service-connected post-operative small bowel obstruction. 3. The currently manifested symptomatology, claimed as Isaac's syndrome and fibromyalgia is not shown to be additional disability which is the proximate result of carelessness, negligence, lack of proper skill, error in judgment, or an event not reasonably foreseeable in the furnishing of medical care by VA, specifically the prescribed use of Lovastatin therapy in November 1999. CONCLUSIONS OF LAW 1. Isaac's syndrome was not incurred in or aggravated by active service, nor as a result of a service-connected disability. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2006); 38 C.F.R. §§ 3.303, 3.310 (2007). 2. Fibromyalgia was not incurred in or aggravated by active service, nor as a result of a service-connected disability. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2006); 38 C.F.R. §§ 3.303, 3.310 (2007). 3. The requirements for compensation pursuant to 38 U.S.C.A. § 1151 (West 2002) for Isaac's syndrome claimed as a result of treatment performed by the VA have not been met. 38 U.S.C.A. §§ 1151, 5103, 5103A (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.159, 3.358, 3.361 (2007). 4. The requirements for compensation pursuant to 38 U.S.C.A. § 1151 (West 2002) for fibromyalgia claimed as a result of treatment performed by the VA have not been met. 38 U.S.C.A. §§ 1151, 5103, 5103A (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.159, 3.358, 3.361 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2005); 38 C.F.R. § 3.159(b) (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005). Proper VCAA notice must inform the claimant of any information and evidence not of record that is necessary to substantiate the claim. The veteran should be informed as to what portion of the information and evidence VA will seek to provide, and what portion of such the claimant is expected to provide. Proper notification must also invite the claimant to provide any evidence in his possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). In the instant case, the provisions of the VCAA have been fulfilled by information provided to the veteran in letters from the RO/AMC dated in September 2002, May 2005, and February 2007. These letters notified the veteran of VA's responsibilities in obtaining information to assist the veteran in completing his claim, identified the veteran's duties in obtaining information and evidence to substantiate his claim, and requested that the veteran send in evidence in his possession that would support his claim. (See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). During the pendency of this appeal, on March 3, 2006, the United States Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a claim, including the degree of disability and the effective date of an award. The veteran received such notice in the February 2007 letter. The veteran has had a meaningful opportunity to participate in his appeal. Moreover, since this claim is being denied, any other notice requirements beyond those cited for service connection claims, are not applicable. Therefore, to move forward with adjudication of this claim would not cause any prejudice to the veteran. If there has been any other deficiency in the notice to the veteran, the Board finds that the presumption of prejudice on the VA's part has been rebutted in this case based on the written notices provided to the veteran by the VA over the course of this appeal. VA has also made reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the current appeal, VA obtained the veteran's service medical records and post-service VA and private medical treatment records. There is no indication that any other treatment records exist that should be requested, or that any pertinent evidence has not been received. VA examinations were provided in connection with the veteran's claim. For the foregoing reasons, the Board therefore finds that VA has satisfied its duty to notify (each of the four content requirements) and the duty to assist pursuant to the VCAA. See 38 U.S.C.A. §§ 5102 and 5103 (West 2002 & Supp. 2006); 38 C.F.R. §§ 3.159(b), 20.1102 (2006); Pelegrini, supra; Quartuccio v. Principi, 16 Vet. App. 183 (2002). Factual Background & Analysis The veteran contends that he is entitled to service connection for fibromyalgia and Isaac's syndrome, claimed as secondary to the service-connected disability of post- operative small bowel obstruction. In the alternative, he contends that these additional disabilities are the proximate result of VA-prescribed use of Mevacor (an anti-cholesterol medication, also known as Lovastatin) and as such warrants entitlement to benefits under to 38 U.S.C.A. § 1151. Service connection was established for post-operative small bowel obstruction in a July 1987 rating decision. Evidence in the claims file shows since then, the residuals of post- operative small bowel obstruction include symptoms of irritable bowel syndrome, such as chronic diarrhea. In November 1999 the veteran was evaluated by Dr. K. for complaints of abdominal cramping and diarrhea. In pertinent part, the record reflects diagnoses of cholecystitis vs. chronic pancreatitis and hyperlipidemia. The veteran was started on Lovastatin. Beginning in March 2000, the veteran began to complain of pains in his legs and fingers. By April 2000, the veteran's symptoms had increased to include fatigue and muscle cramps in his hands, knuckles, right elbow, legs and lower back. Lovostatin was discontinued at this time. In his note, Dr. K. indicated that he did not believe the veteran's symptoms were due to the Lovastatin because the veteran had only been on it for three months. Additional clinical notes reflect that the etiology of the musculoskeletal pain and cramping was unknown. Since that time, the veteran has continued to have muscle aches, cramps, tenderness, and pain, fatigue, and difficulty sleeping. In June 2000, Dr. K. referred the veteran to Dr. M., a rheumatologist, for evaluation. Dr. M. noted the veteran's symptoms of myalgias and muscle cramps had persisted despite the discontinuation of the cholesterol-lowering medication which he had been on. He noted further that "whether this still represented a drug-induced effect seemed to be less likely." He felt it was a possibility that the veteran had a metabolic myopathy that was an acquired metabolic enzyme deficiency, which could be causing his symptoms; however further testing was necessary. The veteran was then evaluated by a VA neurologist in November 2000. The neurologist reported that "myopathy could not be ruled out, but clearly fibromyalgia was a wastebasket diagnosis." Additional neurological studies conducted by the WNC in January and February 2001, reveal that electromyography (EMG) and nerve conduction studies (NCV) were normal. The resulting diagnosis was "myopathy vs. fibromyalgia." In March 2001, the veteran was evaluated by Dr. S. who indicated the veteran was being studied under the "entertaining diagnosis of fibromyalgia, as everything else appeared to be negative." Dr. S. did note that the trigger points for fibromyalgia were sought after, and the veteran had more than 15 tender trigger areas known for fibromyalgia. A March 2001 VA record shows that the veteran was tried on Guafenisine as a treatment for fibromyalgia with no result. A VA outpatient treatment record, dated in April 2001 and authored by Dr. K., reflects "fibromyalgia, rule out glycogen storage disease." Shortly thereafter, Dr. K. referred the veteran to Dr. G., Professor of Neurology at the W. Va. Univ. Medical Center. In his initial letter of correspondence, Dr. K. indicated that thyroid, autoimmune disease, NCV, and EMG studies had been performed. He stated further that he believed "the veteran's physical examination was more consistent with a fibromyalgia situation rather than a myopathy, although it remained a possibility that a glycogen or lipid storage disease was causing the general symptoms of the persistent myalgias." In an April 2001 letter of correspondence, Dr. G. informed Dr. K. that he had evaluated the veteran and his neurological evaluation was normal. He stated, in pertinent part that, "I have no ready explanation for his myalgias. It would be tempting to attribute the onset to the use of Lovastatin which he was taking at the time of symptom onset. However, as noted above, this was promptly discontinued and, therefore, it is difficult to blame the worsening of the current symptoms on the Lovastatin." In a follow-up letter, Dr. G. again noted, in pertinent part, that he was unable to attribute the veteran's myalgias to any specific neurological syndrome and that he planned to conduct further testing, including creatine kinase (CK) studies, repeat EMG/NCV studies, and muscle biopsy. Subsequent correspondence from Dr. G. reflects that the muscle biopsies were non-diagnostic. The EMG/NCV studies showed no evidence of myopathy; however Dr. G. indicated that an isolated finding of a myokymic discharge in the EMG study "raised the question of a potassium channel antibody disorder such as Isaac's disease." With this question raised, the veteran was admitted for in-patient intravenous immunoglobintherapy (IV Ig) infusions under the working diagnosis of Isaac's disease. A May 2002 letter of correspondence from Dr. G. shows that the veteran's myalgias were unresponsive to such treatment. Dr. K. reevaluated the veteran in December 2001 and noted that the veteran had tenderness on several areas. The clinical record reflects a diagnosis of fibromyalgia. VA treatment records since this time intermittently reflect diagnoses of fibromyalgia. At a hearing held at the RO in March 2004, the veteran testified that he was given Lovastatin by Dr. K. to help reduce the chronic diarrhea associated with his post- operative small bowel obstruction. The veteran explained that the current symptomatology was first diagnosed as fibromyalgia, but was later determined to be Isaac's disease by Dr. G. It also appeared that his claim (now withdrawn) for glycogen storage disease was based upon the same set of symptoms, but merely as an alternate diagnosis. He also testified that physical examinations conducted by the Social Security Administration (in connection with his disability benefit determination) revealed diagnoses of Isaac's disease and fibromyalgia. The veteran also acknowledged that no physician had definitely linked Isaac's disease and/or fibromyalgia to residuals of his small bowel obstruction, or to a side effect of the Lovastatin therapy. He did note, however, that Dr. G. and Dr. K. had verbally expressed the possibility that either situation could be the cause of his symptoms; but that they had not done so in writing. The veteran was afforded a VA neurological examination in June 2007. The examiner indicated that he had reviewed the claims file in its entirety and had conducted an interview and physical examination of the veteran. The neurological examination, including mental status, cranial nerves, motor examination, coordination, sensory examination and complex gait maneuvers were without evidence of abnormality. The veteran had trace to 1+ reflexes throughout with downward toes. He did not have ankle clonus. There was no evidence of abnormal sweating, percussion myotonia, cramping, fasciculation, or atrophy. He had normal bulk, tone, and strength throughout. The veteran reported that he was asymptomatic at the time of the examination. Based upon his findings, the examiner opined "it is not at least as least as likely as not that the veteran has Isaac's syndrome due either to service or his service-connected post- operative small bowel obstruction or treatment therefore." He further explained that Dr. G. indicated that the veteran's case only "raised the question" of Isaac's syndrome. He also pointed out that subsequent trials of prednisone and IV Ig, under the working diagnosis of Isaac's syndrome, were not reported by the veteran to be helpful. He further noted that Isaac's syndrome is usually due to autoantibodies directed against the voltage-gated potassium channel (VGKC) and these autoantibody results are not available. Thus, he concluded "there is no credible evidence to support that the veteran actually has Isaac's syndrome." The examiner also opined that "there is not a 50 percent or better probability that the veteran currently has an additional disability (including Isaac's disease and/or fibromyalgia) that was caused or chronically worsened by the VA treatment, specifically prescribing Lovastatin." He also expressed his agreement with the April 2001 opinion of Dr. G. (it is tempting to attribute the onset of symptoms to the use of Lovastatin; however, as it was promptly discontinued, it is difficult to blame the current symptoms on the Lovastatin). Last, the examiner opined that "there is no indication and it is not likely that there was any carelessness, negligence, lack of proper skill, error in judgment or any similar instance of fault on the part of VA personnel in providing treatment for the veteran." The veteran also underwent a VA rheumatology examination in June 2007. Upon physical examination, the veteran's affect, posture and gait were normal. His musculature was well- developed and appeared normal, without atrophy or fasculations observed. All joints exhibited normal range of motion and grip strength was normal. There was diffuse tenderness from the lateral and medial aspect of the knees to the toes, as well as proximal arms and shoulder girdle. There was no tenderness upon patellar compression, no trigger points, scoliosis or kyphosis. Based upon the physical examination and the review of the previous studies available in the record, the examiner opined that "the veteran's symptoms did not fit the criteria for, and were not typical of fibromyalgia." In response to the question of whether there was a 50 percent or better probability that the veteran currently has an additional disability (including Isaac's disease and/or fibromyalgia) that was caused or chronically worsened by the VA treatment, specifically prescribing Lovastatin- the examiner noted in pertinent part that, "Lovastatin and similar drugs can cause myopathy in rare instances. Lovastatin therapy is not associated with fibromyalgia." Therefore, he concluded that "it can be stated confidently that the three month course of Lovastatin therapy in early 2000 has nothing to do with the current symptoms. The rapid resolution of symptoms that can plausible be attributed to Lovastatin is substantiated by the rapid return of creatine phosphokinase (CPK) values to normal after that drug was discontinued." 38 C.F.R. § 3.310 Analysis The veteran does not allege, nor does any of the evidence show, that the current symptoms claimed as Isaac's disease and/or fibromyalgia were incurred during military service. Rather, the veteran has limited his appeal to the issue of secondary service connection. In written statements and personal hearing testimony, the veteran asserts that medication used to treat his service-connected post operative small bowel obstruction caused side effects of Isaac's disease and fibromyalgia. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303. As a general matter, service connection for a disability on the basis of the merits of such claim is focused upon (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. See Cuevas v. Principi, 3 Vet. App. 542 (1992); Rabideau, 2 Vet. App. 141. Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2007). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). When aggravation of a nonservice- connected disability is proximately due to or the result of a service-connected disorder, the veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Id. In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence is required. Grottveit v. Brown, 5 Vet. App. 91 (1993); see also Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The Court has also held that the Board must determine how much weight is to be attached to each medical opinion of record. See Guerrieri v. Brown, 4 Vet. App. 467 (1993). VA is free to favor one medical opinion over another provided it offers an adequate basis for doing so. See Owens v. Brown, 7 Vet. App. 429 (1995). Based upon the evidence of record, the Board finds service connection for Isaac's disease and fibromyalgia claimed as secondary to the service-connected post-operative small bowel obstruction, including treatment thereof, is not warranted. As noted, the veteran was prescribed Lovastatin in November 1999. The veteran has testified that it was prescribed to help decrease his chronic diarrhea symptoms. The veteran also testified that no doctor had actually ever definitively linked his symptoms to either the medication or directly to his service-connected small bowel obstruction. To that end, he has not proffered any written medical opinions which establish such a causal relationship. The Board is likewise unable to find any competent medical evidence in the record which establishes that Isaac's disease and fibromyalgia (or more appropriately, the symptomatology claimed as Isaac's disease and fibromyalgia) are related to military service; or are proximately due to, or the result of the service-connected post-operative small bowel obstruction or medication used to treat the post-operative small bowel obstruction. Significantly, the Board has not observed any medical evidence that confirms the veteran's currently has Isaac's disease and/or fibromyalgia. The Board notes that a myriad of tests have been conducted by neurologists, rheumatologist, and general practitioners alike, in an effort to determine the etiology of the veteran's symptoms and provide a conclusive diagnosis for his symptomatology. As it stands though, the record clearly reflects that the purported "diagnoses" of Isaac's disease and fibromyalgia are no more than diagnoses of exclusion or working diagnoses; and the specific cause of the veteran's symptomatology remains to be determined. The Board also notes that the SSA disability file do not reflect that any independent examinations and tests were performed to arrive at diagnoses of Isaac's disease and fibromyalgia. It is also noted that most recently in June 2007 two VA examiners who conducted an in-depth review of the entire medical record and an objective examination of the veteran, have confirmed that the veteran does not currently have Isaac's disease or fibromyalgia. Specifically, the VA neurologist noted that there was no confirmed diagnosis of Isaac's disease in the record, except in the context that the veteran's symptoms were noted to have "raised the question" Isaac's disease, and subsequent trials of prednisone and IV Ig (therapy often used to treat Isaac's disease) was not helpful. The VA rheumatologist similarly opined that the veteran's current symptoms did not fit the criteria for, and were not typical of fibromyalgia. Thus, while it is not disputed that the veteran has symptoms which manifest as muscle aches, cramps, tenderness, and pain; fatigue; and difficulty sleeping; the available medical evidence does not conclusively establish that these symptoms are attributable to the specific disease entities of Isaac's syndrome and/or fibromyalgia. The Board finds the 2007 VA examiners' respective opinions that the veteran's symptoms are not typical of fibromyalgia and that there is no credible evidence that the veteran has Isaac's disease, to be persuasive in this matter. To the extent, that the veteran believes he has Isaac's disease and fibromyalgia, and as such it is due to his service-connected postoperative small bowel obstruction, he is not a licensed medical practitioner and is not competent to offer opinions on questions of medical diagnosis and/or causation. See Grottveit v. Brown, 5 Vet. App. 91 (1993); see also Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Congress has specifically limited entitlement to service- connection for disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. §§ 1110. Hence, in the absence of proof of Isaac's disease and fibromyalgia (and, if so, of a nexus between that disability and service, or a service-connected disability), there can be no valid claim for service connection. See Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 143-144 (1992). Since the Board notes there is no competent medical evidence showing the veteran currently has Isaac's disease and/or fibromyalgia, the appellant is not entitled to disability compensation for those disorders as secondary to service-connected post operative small bowel obstruction. Therefore, the Board finds entitlement to service connection must be denied. 38 U.S.C.A. § 1151 Analysis The veteran's claim for compensation based on 38 U.S.C.A. § 1151 was raised at an RO hearing held in March 2004. He contends that he developed additional disabilities of Isaac's syndrome and fibromyalgia due to medication that was improperly prescribed by VA. 38 U.S.C.A. § 1151 states that where any veteran suffered an injury, or aggravation of an injury, as a result of VA hospitalization, medical, or surgical treatment, and such injury or aggravation results in additional disability or death, disability or death compensation and dependency and indemnity compensation shall be awarded in the same manner as if such disability, aggravation, or death were service- connected. Additionally, it is required that the proximate cause of the disability or death was (1) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA in furnishing hospital care, medical/surgical treatment, or examination; or (2) an event not reasonably foreseeable. 38 U.S.C.A. § 1151 (West 2002). VA regulations codifying the requirements for claims requesting benefits under 38 U.S.C. 1151(a) filed on or after October 1, 1997, became effective September 2, 2004. 69 Fed. Reg. 46426 (Aug. 3, 2004). These regulations provide that benefits under 38 U.S.C. 1151(a), for additional disability or death due to hospital care, medical or surgical treatment, examination, training and rehabilitation services, or compensated work therapy program, require actual causation not the result of continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished, unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. The additional disability or death must not have been due to the veteran's failure to follow medical instructions. 38 C.F.R. § 3.361 (2007). After a careful review of the evidence of record, the Board finds no competent medical evidence in the record to substantiate the veteran's contentions that he suffered additional disabilities of Isaac's disease and/or fibromyalgia due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing medical treatment, or that the proximate cause of any additional disability was the use of Lovastatin prescribed by the VA. At the outset, the Board notes that the veteran has symptoms which manifest as muscle aches, cramps, tenderness, and pain; fatigue; and difficulty sleeping. The evidentiary record does not, however, currently reflect that these symptoms have been confirmed as Isaac's disease and/or fibromyalgia. As noted, a host of tests were conducted by specialists, but they were unable to confirm that the symptoms were manifestation of diagnoses Isaac's disease and fibromyalgia. It is clear upon the Board's review of the record that Isaac's disease and fibromyalgia were no more than "exclusionary diagnoses" or "working diagnoses;" and the specific disease entity or entities underlying the veteran's symptoms remain to be determined. The crux of the issue, however, is whether any additional disability was actually the result of VA treatment, and not coincidental or a continuation or progression of the disability for which treatment was provided. See 38 C.F.R. § 3.358(c). Here, the only medical opinions addressing that question were provided by the VA examiners, and they clearly state that the veteran's currently manifested symptoms (claimed as Isaac's disease and fibromyalgia) were not incurred as a result of VA treatment, specifically the use of Lovastatin. They also found no indication and determined that it is not likely that there was any carelessness, negligence, lack of proper skill, error in judgment or any similar instance of fault on the part of VA personnel in providing treatment for the veteran. The veteran has not provided any competent medical evidence or opinions to the contrary and indeed testified that no doctor had actually ever definitively linked his symptoms to the Lovastatin. The Board has considered the veteran's contentions, but again notes that as a lay person he is not competent to provide evidence as to matters requiring specialized medical knowledge, skill, expertise, training or education such as whether or not he has a specific disease or disorder or determine the etiology of that disease or disorder. Layno v. Brown, 6 Vet. App. 465 (1994). Therefore, his assertions of medical causation and etiology, absent corroboration by objective medical evidence and opinions, are of extremely limited probative value towards establishing a link between his current symptomalogy and the medication prescribed by the VA. The uncontroverted medical evidence has found no correlation between the current symptoms and VA treatment, specifically the use of Lovastatin, nor is there any indication and it is not likely that there was any carelessness, negligence, lack of proper skill, error in judgment or any similar instance of fault on the part of VA personnel in providing treatment for the veteran. As such, the Board finds entitlement to compensation based upon 38 U.S.C.A. § 1151, must be denied. When all the evidence is assembled VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The preponderance of the evidence is against the veteran's claim of service connection for Isaac's disease and fibromyalgia. ORDER Service connection for Isaac's syndrome secondary to service- connected post-operative small bowel obstruction is denied. Service connection for fibromyalgia secondary to service- connected post-operative small bowel obstruction is denied. Entitlement to compensation benefits under 38 U.S.C.A. § 1151 (West 2002) for Isaac's syndrome is denied. Entitlement to compensation benefits under 38 U.S.C.A. § 1151 (West 2002) for fibromyalgia is denied. ____________________________________________ CHERYL L. MASON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs