Citation Nr: 1320132	
Decision Date: 06/21/13    Archive Date: 07/02/13

DOCKET NO.  10-31 062	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Columbia, South Carolina


THE ISSUE

Entitlement to service connection for sarcoidosis.


REPRESENTATION

Veteran represented by:	Disabled American Veterans


WITNESS AT HEARING ON APPEAL

Veteran


ATTORNEY FOR THE BOARD

S. Becker, Associate Counsel


INTRODUCTION

The Veteran served on active duty from July 1945 to November 1946.

This matter comes before the Board of Veterans' Appeals (Board) from a January 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina.  Service connection for sarcoidosis was denied therein.  The Veteran appealed this determination.

In May 2012, the Veteran testified regarding this matter before the undersigned Veterans Law Judge at a video conference hearing.  This matter was remanded by the Board for additional development in June 2012.  Such development now has been completed or at least substantially completed to the extent possible, as discussed below.  Adjudication thus may proceed if otherwise in order.  Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with); aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002).

The following determination is based on review of the Veteran's claims file in addition to his Virtual VA "eFolder."  Please note that this matter has been advanced on the Board's docket.  38 U.S.C.A. § 7107(a)(2); 38 C.F.R. § 20.900(c).


FINDING OF FACT

The Veteran currently does not have sarcoidosis or residuals thereof, and even if he did such has not been established as related to his service in any manner.



CONCLUSION OF LAW

The criteria for establishing service connection for sarcoidosis have not been met.  38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1153, 1154, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2012).


REASONS AND BASES FOR FINDING AND CONCLUSION

I.  Duties to Notify and Assist

VA has a duty of notification regarding a claim for VA benefits.  38 U.S.C.A. §§ 5103; 38 C.F.R. § 3.159.  VA must notify the claimant and his representative, if any, prior to initial adjudication by the agency of original jurisdiction (AOJ) of any information and any evidence not of record that is necessary to substantiate the claim, that VA will seek to obtain, and that the claimant is expected to provide.  38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002).  Notification that an evaluation and an effective date will be assigned if service connection is granted for a disability also must be included.  Dingess v. Nicholson, 19 Vet. App. 473 (2006).  

Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required.  Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (overturning Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007)); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007).  None is found by the Board.  Via letters dated in April 2009 and March 2010, the Veteran and his representative (his representative at the time in April 2009 and his current representative in March 2010) were notified of the criteria for establishing service connection, the evidence required in this regard, and his and VA's respective duties for obtaining evidence.  They also were notified of how VA determines an evaluation and effective date if service connection for a disability is awarded.  It follows that the required notification was provided prior to the initial adjudication by the RO/AOJ in the January 2010 rating decision.

In addition to the duty to notify, VA has a duty to assist with respect to a claim for VA benefits.  38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c).  This includes a requirement to aid the claimant in the procurement of relevant records.  38 U.S.C.A. § 5103A(b-c); 38 C.F.R. § 3.159(c)(1-3).  VA also is required to provide a medical examination and/or obtain a medical opinion when necessary.  38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4).

The Veteran's service treatment records, service personnel records, and VA treatment records have been obtained by VA.  The service personnel records and some of the VA treatment records were obtained in compliance with the Board's June 2012 remand.  Also pursuant to this remand, a June 2012 letter requested that the Veteran either submit records from the only two private physicians identified by him as providing pertinent treatment or furnish enough information to identify and locate the records along with an authorization for their release to VA.  He responded by indicating that such records would be with his VA treatment records.  He also responded by submitting such records.  Reference was made to additional pertinent treatment records from private physicians, in particular records for the years immediately following service, at the May 2012 hearing.  However, the Veteran's representative indicated that there was no way to procure them since the physicians have passed away.

A VA medical examination was conducted in September 2012, as contingently directed in the aforementioned remand.  The examiner opined as to diagnosis after reviewing the claims file, interviewing the Veteran, and undertaking an assessment of him.  The examiner also opined as to whether or not the diagnosis is related to the Veteran's service.  Each of these opinions was found by the Board to be deficient in February 2013, as position taken again herein, so opinions from a Veteran's Health Administration (VHA) expert were requested.  They were received in March 2013.  Discussed below is that no deficiencies in them are found.  Accordingly, sufficient detail has been supplied so that this determination is fully informed.  The VA medical examination complete with opinions and VHA opinions thus collectively are adequate.  Barr v. Nicholson, 21 Vet. App. 303 (2007).

Of additional note, the individual presiding over a hearing must fully explain the issues and suggest the submission of evidence that may have been overlooked.  38 C.F.R. § 3.103(c)(2); Bryant v. Shinseki, 23 Vet. App. 488 (2010).  The undersigned identified service connection for sarcoidosis as the sole issue on appeal at the outset of the May 2012 hearing.  It was explained by the undersigned and the Veteran's representative in that information was elicited from him concerning the history of his relevant symptoms and why he believes they are attributable to his service.  Information also was elicited from him concerning his history of relevant treatment.  A remand to allow for the submission or procurement of missing treatment records was mentioned.  Such remand indeed occurred, as noted above.

Neither the Veteran nor his representative has identified any further development necessary for a fair adjudication of the claim decided herein that has not been completed.  The record also does not indicate any further development.  Therefore, the Board finds that no further notice or assistance is required and that VA's duties to notify and to assist have been satisfied.  Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002).  Adjudication thus may proceed without prejudice to the Veteran.  Bernard v. Brown, 4 Vet. App. 384 (1993).

II.  Service Connection

The Veteran contends that he has sarcoidosis or residuals thereof due to his service.  Specifically, he contends that he was exposed to chemicals such as insecticides, herbicides, and pesticides during service in that he killed grass and insects with spray, cut bushes, and raked pine brush.  He further contends that he drank and otherwise used water contaminated with chemicals such as insecticides, herbicides, and pesticides during service.  The Veteran does not contend that he manifested sarcoidosis or symptoms thereof during service as a result of these activities.  He also does not contend that he manifested sarcoidosis or symptoms thereof immediately after his service.  Rather, he essentially contends that there was a latency period as first manifestation was not until approximately 1960.

Service connection means that the facts, shown by evidence, establish that an injury or disease resulting in disability was incurred in service, or if preexisting service, was aggravated therein.  38 C.F.R. § 3.303(a); 38 U.S.C.A. § 1110.  To establish service connection, there generally must be (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus between the current disability and the in-service disease or injury.  Hickson v. West, 12 Vet. App. 247 (1999); Barr, 21 Vet. App. at 303.  Service connection also may be established for any disease diagnosed after discharge when the evidence shows it was incurred in service.  38 C.F.R. § 3.303(d).  

Sarcoidosis is a chronic disease.  38 U.S.C.A. § 1101(3); 38 C.F.R. § 3.309(a).  For chronic diseases, service connection may be established through chronicity or continuity of symptomatology.  Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).  A chronic disease during service is shown when there is a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time.  38 C.F.R. § 3.303(b).  Merely isolated findings are insufficient, as is a diagnosis including the word chronic.  Id.  Subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected unless clearly attributable to intercurrent causes.  Id.; Barr, 21 Vet. App. at 303.  Continuity of symptomatology after service is required if the disease is noted during service but is not chronic, or where a determination that it is chronic may legitimately be questioned.  38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997).

If certain requirements are met, service connection is presumed for chronic diseases.  38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309.  The veteran must have served 90 days or more either during a period of war or after December 31, 1946.  38 U.S.C.A. § 1112(a); 38 C.F.R. § 3.307(a)(1).  Manifestation of the chronic disease, though not necessarily diagnosis, also must have been to a compensable degree within one year from the date of separation from service.  38 U.S.C.A. § 1112(a)(1); 38 C.F.R. §§ 3.307(a)(2-3), (c).  Affirmative evidence rebutting in-service incurrence or aggravation of a chronic disease must be taken into consideration even if the aforementioned requirements are met.  38 U.S.C.A. §§ 1113, 1153; 38 C.F.R. §§ 3.307(d), 3.309(a).

The Board must identify the evidence it finds to be persuasive and unpersuasive and explain why any favorable evidence is unpersuasive.  Gabrielson v. Brown, 7 Vet. App. 36 (1994), Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990).  Therefore, an assessment of the probative value of the medical evidence and the lay evidence is required.  Evidence indeed may be discounted in light of inherent characteristics and its relationship to other evidence.  Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997).  

Factors in assessing the probative value of a medical opinion include the qualifications and expertise of the examiner, access to the claims file or other pertinent evidence, the scope of the examination, the accuracy of the factual premise underlying the opinion, the thoroughness and detail of the opinion, the rationale offered for the opinion, and the degree of certainty provided.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Prejean v. West, 13 Vet. App. 444 (2000); Black v. Brown, 10 Vet. App. 297 (1997); Ardison v. Brown, 6 Vet. App. 405 (1994); Sklar v. Brown, 5 Vet. App. 140 (1993); Reonal v. Brown, 5 Vet. App. 458 (1993); Guerrieri v. Brown, 4 Vet. App. 467 (1993).  A lay person is competent to relate observations or that which is within his personal knowledge.  Layno v. Brown, 6 Vet. App. 465 (1994).  Credibility factors to take into consideration with respect to lay testimony and statements include interest, self-interest, bias, inconsistency, facial implausibility, bad character, malingering, desire for monetary gain, and witness demeanor.  Pond v. West, 12 Vet. App. 341 (1999); Macarubbo v. Gober, 10 Vet. App. 388 (1997); Caluza v. Brown, 7 Vet. App. 498 (1995); Cartright v. Derwinski, 2 Vet. App. 24 (1991).  "[T]he Board cannot determine that lay testimony or a lay statement lacks credibility merely because it is unaccompanied by contemporaneous medical evidence."  Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006).  However, the lack of such evidence along with other factors may lead to the determination that the lay testimony or statement is not credible.

When there is an approximate balance of positive and negative evidence, any reasonable doubt is resolved in favor of the claimant.  38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49.  The claimant thus prevails when the evidence supports the claim or is in relative equipoise but does not prevail when the preponderance of the evidence is against the claim.  Only the most salient and relevant evidence must be discussed, although all the evidence must be reviewed.  Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000).

Service personnel records, to include the Veteran's DD-214, reflect that his principal duties were basic or general in nature.  They further reflect that he was stationed at Camp Lejeune.  Service treatment records are silent with respect to sarcoidosis.  They reveal that no defects were found at the Veteran's April 1945 entrance examination or October 1946 separation examination.  His respiratory system was normal and chest X-ray (CXR) was negative at each of these examinations.

Old VA treatment records document the following.  The Veteran was hospitalized in November and December 1960 suffering from an acute episode of many symptoms to include dry rales.  Hodgkin's disease, mononucleosis, lymphoma, and sarcoid lupus variously were suspected.  CXR showed hilar lymphadenopathy.  Lymph node biopsy showed dermatopathic lymphadenitis (lipomelanotic reticulosis).  Sternal bone marrows were not revealing.  Sarcoidosis, incompletely diagnosed, and sarcoidosis, probable, were the diagnoses made.  In January 1962, the Veteran was asymptomatic.  CXR was normal.  The diagnosis was sarcoidosis (incompletely diagnosed).

In March 2009, Dr. C.P. III indicated in a letter that the Veteran was diagnosed with sarcoidosis in the 1960's.  Dr. C.P. III further indicated that the etiology of the Veteran's sarcoidosis is unknown.

Recent VA treatment records reveal the following.  A November 2007 CXR showed an area of atelectasis/infiltrate in the left lower lobe.  An April 2008 CXR showed a small nodular density in the right lower lobe.  The lungs were otherwise clear.  A computerized tomography (CT) scan of the Veteran's thorax in May 2008 showed chronic obstructive pulmonary disease with pulmonary scarring, a skin lesion, and a lipoma but no pulmonary nodules or other abnormalities.  A September 2008 CXR showed a possible minimal interstitial infiltrate in the right base.  The Veteran reported having sarcoidosis that month.  It was noted that there was no record in this regard.  In December 2008, history of pulmonary sarcoidosis was diagnosed.  In March 2009, uveitis of the left eye secondary to sarcoidosis was referenced.  Sarcoidosis with history of iritis in the left eye was diagnosed at that time.  The Veteran indicated being diagnosed in the 1960's according to his military records.  A September 2009 CXR showed no change from a prior CXR from September 2008.  There particularly was no change in the contour of the hila or mediastinum.  It was determined that same month that "CXR and CT thorax were not consistent with prior sarcoidosis."  An October 2010 CXR showed an ill-defined opacity in the right hilum, scarring there and in both lower lobes, and a nonspecific nodule overlying left breast tissue.  In August 2011, the Veteran indicated he has sarcoid.  It was noted that sarcoid could explain his abnormal CXR, but that a determination would await records to be brought in by him.  In March 2012, the Veteran again indicated he has sarcoid.  CXR was noted to be abnormal.

The examiner who conducted the September 2012 VA medical examination, a resident, opined that the Veteran has sarcoidosis.  Noted in this regard was that this diagnosis was made as of 1960 and that there had been past treatment for sarcoid.  A December 2011 CXR, which showed mild interstitial scarring at the lung bases, also was reviewed.  The VA examiner opined that the Veteran's sarcoidosis was less likely than not incurred in or caused by his service to include exposure to pesticides therein.  Then, the examiner indicated that no opinion could be rendered regarding whether the Veteran's sarcoidosis is related to pesticide exposure during service.  This was noted to be due to the fact that the exact cause of sarcoidosis has yet to be identified.  As such, the examiner stated that it would be "speculative to opine on this case."

In a March 2013 single sentence statement from T.B., M.D., PhD, indicated that there is a possibility that the Veteran's use of insecticides during wartime service led to the development of his sarcoidosis.

The VHA expert, a pulmonary specialist, opined in March 2013 that no definitive diagnosis of sarcoidosis ever had been made with respect to the Veteran.  With respect to the 1960's, the presence of non-caseating granulomas in some type of tissue biopsy, usually of the lung parenchyma, endobronchial lesion if present, or hilar or mediastinal lymph nodes, was indicated to be required for a definitive diagnosis.  It was noted that none of these sites was biopsied in 1960, and the Veteran's left axillary lymph node and bone marrow that were biopsied did not show the presence of any type of granulomatous lesion.  Indeed, it was noted that these biopsies showed no findings at all suggestive of sarcoidosis.  The need for investigating and eliminating for consideration possible causes other than sarcoidosis if non-caseating granulomas are found next was indicated.  It was pointed out that, even though these granulomas were not found, sarcoidosis was just one of the differential diagnoses entertained regarding the Veteran in 1960.  It further was pointed out that such a diagnosis was never proven, as the history and radiographic findings were totally non-specific.  Acknowledgement finally was given to the special instance in which a presumptive sarcoidosis stage I diagnosis is made without biopsy, in a patient who (unlike the Veteran in 1960) is totally asymptomatic with incidental radiographic findings such as bilateral hilar and mediastinal lymphadenopathy without pulmonary parenchymal involvement in a CXR suggestive of sarcoidosis.

With respect to recently, that an ophthalmologist's diagnosis is the only evidence of sarcoidosis was highlighted by the VHA expert.  This diagnosis was determined to be based on the Veteran's self-reported history, with no apparent attempt at confirmation.  Reference was made to the lack of clinical or radiographic evidence of chronic pulmonary residual damage via repeat assessments, CXRs, and CT scans.  Noted in this regard was that the fibrosis and scarring seen in the lungs with chronic sarcoidosis stage III or IV is usually localized in the upper lobes rather than the lower lobes (like the Veteran displays).  Mention was made of the lack of evidence of respiratory function impairment, as pulmonary function studies have not been performed.  It finally was pointed out that there is no indication the Veteran has had systemic therapy for sarcoidosis to include oral steroids.  His eye drops were conceded to be corticosteroids, but these were pointed out to be administered locally for treatment of uveitis/iritis. 

The VHA expert finally essentially opined that, in the unlikely case the Veteran did have sarcoidosis stage I when seen in 1960, such could not be attributed to his service without resort to speculation.  It was indicated that current medical knowledge establishes no known etiology for sarcoidosis.  Proposed but as of yet unproven possibilities including exposure to insecticides, herbicides, and pesticides as well as infectious agents and genetic-hereditary predisposition were set forth.  The latency period between the aforementioned exposure and manifestation of sarcoidosis was noted to be unknown.  Finally, that the invading route is believed to be inhalation rather than ingestion was noted.  It thus was opined that drinking contaminated water less likely than not causes sarcoidosis.

Based on the above, the Board finds that service connection for sarcoidosis is not warranted.  All necessary requirements for establishing entitlement to this benefit are not met.

A current disability exists when there is a disability at the time a claim is filed or at any time during the pendency of the claim.  McClain v. Nicholson, 21 Vet. App. 319 (2007).  Here, the Veteran filed his claim in April 2009.  He has not had a clinically demonstrated diagnosis of sarcoidosis or residuals thereof at any point within the period from then to present.  The VHA expert opined with confidence that the Veteran has never had sarcoidosis.  It follows that he has never had residuals thereof.  This includes within the aforementioned period.  The opinion was not based on assessment of the Veteran.  Yet it was based on review of the claims file, which contains lay evidence from him in addition to medical evidence such as assessments and the September 2012 VA medical examination.  This ensured that it was not based on an inaccurate factual premise.  The rationale for it was clear and lengthy.  The lack of clinical or radiographic evidence indicative of sarcoidosis or residuals thereof was noted, as was the lack of sarcoidosis treatment.  Therefore, substantial probative value is assigned to the VHA expert's negative opinion.

One conflicting opinion exists.  The examiner who performed the September 2012 VA medical examination rendered a positive opinion that the Veteran has sarcoidosis.  However, this opinion is assigned very little probative value.  The examiner, as opposed to being a pulmonary specialist, was a resident.  The opinion was based on assessment of the Veteran, interview of him, as well as review of the claims file to include lay evidence from him in addition to medical evidence in the form of assessments.  The review appears to have been insufficient, since the claims file does not completely support the examiner's statement that sarcoidosis was diagnosed in the 1960's.  Other than this statement, the only other explanation for the opinion provided is that there had been past treatment for sarcoid.  The rationale for it is not thorough and detailed, in other words.  It also is not clear.  There was no discussion of the period from April 2009 to present, only of the period almost 50 years earlier.  It does not follow that a diagnosis, even if present, then means that the same diagnosis or at least residuals thereof is present now.

Other than the aforementioned opinions, VA treatment records within the period from April 2009 to present contain conflicting information regarding a sarcoidosis diagnosis.  Such a diagnosis specifically was not made on numerous occasions.  History of pulmonary sarcoidosis was diagnosed a few months prior to the aforementioned period.  Use of the word history implies a past rather than a present problem, however.  Sarcoidosis finally was diagnosed the month prior to the aforementioned period.  Yet this diagnosis was made by an ophthalmologist with expertise regarding the eyes, as noted by the VHA expert, as opposed to a physician with expertise with pulmonary conditions.  There is no indication it was based on review of the claims file.  Indeed, the only basis for it was the assessment performed and interview of the Veteran.  The assessment is not pertinent, since it concerned his eyes.  Mere transcription of self-reported history by a medical professional is not sufficient.  Leshore v. Brown, 8 Vet. App. 406 (1995).  This history must be accurate.  Kowalski v. Nicholson, 19 Vet. App. 171 (2005); Coburn v. Nicholson, 19 Vet. App. 427 (2006).  The private medical statements note only the apparent presence of the disease, without any explanation of the basis for a diagnosis of such.  Accordingly, they have very little probative value.  Here, the above discussion shows that the Veteran's self-reported history of sarcoidosis is inaccurate.  Of final note is that no rationale, let alone a thorough and detailed rationale, for the sarcoidosis diagnosis was provided by the ophthalmologist.  It is reiterated that a history of sarcoidosis, even if shown, does not automatically mean there presently is sarcoidosis.  The ophthalmologist's diagnosis thus is of very little probative value.

It is clear that the Veteran believes he has sarcoidosis.  As there is no indication that the Veteran has any medical background, he is a lay person.  He is competent to indicate his symptoms because he personally experiences them.  He also is credible in this regard because there is no reason for doubt.  Recent VA treatment records indeed confirm the presence of underlying pathology to account for these symptoms.  However, a lay person is competent to diagnose a condition only when (1) the lay person is competent to identify the medical condition, (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.  Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).  Conditions such as flat feet, a dislocated shoulder, certain skin ailments, tinnitus, and varicose veins are examples of conditions a lay person is competent to identify.  Jandreau, 492 F.3d at 1372; Woehlaert v. Nicholson, 21 Vet. App. 456 (2007); Charles v. Principi, 16 Vet. App. 370 (2002); Falzone v. Brown, 8 Vet. App. 398 (1995).  Sarcoidosis, in contrast, is not a condition a lay person like the Veteran is competent to identify.  It is not simple like a dislocated joint. The VHA expert further indicated that diagnostic testing, specifically a biopsy or at least a radiograph such as a CXR, is required.  A contemporaneous medical diagnosis has not been reported by the Veteran, and he has not described symptoms supporting a later medical diagnosis.  Indeed, this is impossible as there is no sufficient present sarcoidosis diagnosis.

In sum, the preponderance of the medical and lay evidence does not establish that the Veteran currently has sarcoidosis or residuals thereof.  Reasonable doubt accordingly is inapplicable.  There can be no valid claim absent a current disability.  Brammer v. Derwinski, 3 Vet. App. 223 (1992).  Thus, service connection is denied due to the lack of a current disability.  Discussion of the other requirements for establishing service connection accordingly need not be addressed.  The following discussion of them is undertaken because, even if the Veteran did currently have sarcoidosis or residuals thereof, service connection still would not be warranted.

Due consideration shall be given to the circumstances of a veteran's service.  38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.304(d).  Here, the Veteran's service personnel records reflect that he performed basic or general duties.  He is competent to recount that these duties included killing grass and insects with spray, cutting bushes, and raking pine brush because these would have been personally experienced by him.  He further is credible to so recount since there is no reason for doubt.  A basic or general servicemember undertaking the aforementioned activities is facially plausible.  Nothing suggests that the Veteran did not undertake them.  His demeanor at the May 2012 hearing did not convey any dishonesty.  As such, his use of insecticides, herbicides, and pesticides during service is established.

The Veteran additionally has recounted drinking and otherwise using water contaminated with chemicals such as insecticides, herbicides, and pesticides.  His recount of drinking and otherwise using water, such as for bathing, is competent for the same reason as above.  Yet he did not specifically recount observing any chemicals being added to the water or otherwise having personal knowledge that any chemicals were in the water.  He is not competent in this regard, in other words.  The Veteran's credibility in the aforementioned regard therefore need not be discussed.

To the extent, if any, the Veteran contends he was exposed to contaminated water by virtue of being stationed at Camp Lejeune, ground water contamination there from various chemicals has been acknowledged by VA.  Yet the recognized period of contaminated water is from 1957 to 1987.  VA Revised Fast Letter 11-03 (Jan. 28, 2013); VA Revised Training Letter 11-03 (Nov. 29, 2011).  This equates to a period that began over 10 years after the Veteran separated from service.  It therefore equates to a period that began at least over 10 years after he was at Camp Lejeune.  Further, only 14 diseases have been identified as potentially being associated with exposure to one or more of the chemicals in the contaminated water.  VA Revised Training Letter 11-03 (citing a 2009 National Academy of Sciences' National Research Council report).  Sarcoidosis was not one of them.  The VHA expert similarly opined that contaminated water, at least with respect to drinking, is unlikely to cause sarcoidosis.  A succinct yet clear rationale, that inhalation rather than ingestion is believed to be the invading route, was provided in support of this opinion.  Other characteristics of this opinion are the same as the VHA's expert opinion regarding diagnosis.  Substantial probative value therefore is assigned to it.

Of import is that the Veteran does not contend he manifested sarcoidosis or symptoms of sarcoidosis during service or within the first post-service year.  He indeed identified 1960 as the point of first manifestation.  He is competent in this regard because he would have personally experienced the absence and then presence of the disease or at least its symptoms.  He also is credible because there is no reason for doubt.  Indeed, service treatment records and early VA treatment records support his testimony.  Service connection based on chronicity or continuity of symptomatology therefore cannot be awarded.  Service connection also cannot be presumed.  

That leaves for consideration only a nexus between the Veteran's use of insecticides, herbicides, and pesticides during service and sarcoidosis or residuals thereof.  There are three medical opinions concerning such a nexus.  While two are assigned no probative value, one is assigned substantial probative value.

The opinion of Dr. C.P. III, which is neither positive nor negative, is assigned no probative value.  It is unclear whether or not Dr. C.P. III has expertise in the pulmonary field.  It further is unclear whether or not the opinion was based on review of the claims file, though presumably it was based on interview of the Veteran and assessment of him since Dr. C.P. III treated him.  In any event, a thorough and detailed rationale was not provided in support of the opinion.  Indeed, no rationale whatsoever was provided.  There was no explanatory discussion of how the opinion made was reached.  Dr. T.B.'s statement indicates a "possibility" that inservice insecticide use led to the development of sarcoidosis.  Such a statement has no probative value as to etiology because it is an opinion neither for nor against an etiological relationship.  A medical opinion is not entitled to any probative value if it consists only of a conclusion without a supporting explanation.  Nieves-Rodriguez, 22 Vet. App. at 295; Stefl, 21 Vet. App. at 120.  

Like Dr. C.P. III's opinion, the opinion of the examiner who performed the September 2012 VA medical examination is assigned no probative value.  It indeed is contradictory, unclear, and incomplete in addition to being from a resident instead of an expert and being made following insufficient review of the claims file.  The examiner first concluded there is no nexus but then concluded that no determination on nexus can be made without speculation.  By stating that the exact cause of sarcoidosis has yet to be identified, the examiner could be indicating that either the cause generally is unknown or that the cause in the Veteran's case is unknown.  There was no rationale, let alone a thorough and detailed one, in this regard.  Like  Dr. C.P. III's opinion, there was no explanatory discussion whatsoever.  Nieves-Rodriguez, 22 Vet. App. at 295; Stefl, 21 Vet. App. at 120.  Pesticides finally were addressed in the opinion, but not insecticides or herbicides.

The VHA expert's opinion, which is neither positive nor negative, is assigned substantial probative value.  As with the opinion regarding diagnosis, the nexus opinion was made with confidence, was not based on assessment of the Veteran but was based on review of the claims file containing lay evidence from him in addition to medical evidence such as assessments and the September 2012 VA medical examination, and was supported by a clear rationale of adequate length.  In particular, it was noted that multiple etiologies for sarcoidosis to include exposure to insecticides, herbicides, and pesticides have been proposed but that none have been proven.  The latency period, if any, between such exposure and manifestation of sarcoidosis or symptoms thereof indeed was noted to be unknown.

An examiner's conclusion that a nexus opinion is not possible without resort to speculation is a medical conclusion just as much as a conclusive opinion.  Jones v. Shinseki, 23 Vet. App. 382 (2010).  A few instances in which the nexus or etiology of a disability cannot be determined indeed have been identified.  These include when there is a limit to even the most current medical knowledge, when information that could only have been collected in service is missing, or when application of current medical knowledge yields multiple possible etiologies with none more likely than not the cause of a disability.  Id.  Given these instances, VA need not order multiple medical examinations until a conclusive opinion is rendered.  Id.  Use of the phrase "without resort to mere speculation" cannot be used as a substitute for the full consideration of the evidence, however.  Id.  The basis for such an opinion further must be provided or otherwise apparent.  Id.  Here, it is reiterated that the VHA expert reviewed the contents of the claims file.  There accordingly was full consideration of the evidence.  The VHA expert also identified a limit to current medical knowledge as the reason a conclusive nexus opinion could not be provided.

Given the probative value assigned to it as compared to the assignment of no probative value to the other opinions, the Board finds the VHA expert's opinion to be the most persuasive medical evidence of record concerning nexus.  The only other nexus evidence is from the Veteran.  He clearly believes there is a connection between sarcoidosis or residuals thereof and his in-service exposure to insecticides, herbicides, and pesticides.  Lay evidence sometimes can be sufficient to prove nexus.  Davidson, 581 F.3d at 1313; Jandreau, 492 F.3d at 1372; Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010); Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010).  However, the question of whether there exists a nexus in this case falls outside the province of a lay person.  It is a medical question.  The complex nature of sarcoidosis is notable in this regard.  So is that numerous potential causes have been posited but none have been medically proven, as discussed above.  Only those with specialized medical knowledge, training, and expertise are competent where the determinative issue is one of medical causation.  Jones v. West, 12 Vet. App. 460 (1999).  Therefore, the Veteran is not competent to render an opinion that there exists a nexus between sarcoidosis or residuals thereof and his service.  Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau, 492 F.3d at 1372.  His credibility in this regard need not be addressed in light of his lack of competence.

The preponderance of the medical and lay evidence, in conclusion, not only does not establish that the Veteran currently has sarcoidosis or residuals thereof.  It also does not establish that current sarcoidosis or residuals thereof, even if he had such currently, has a nexus to his exposure to insecticides, herbicides, and pesticides during service.  Once again, then, reasonable doubt is inapplicable.  Service connection thus is denied due to a lack of a nexus to service in addition to the lack of a current disability.  


ORDER

Service connection for sarcoidosis is denied.



____________________________________________
BARBARA B. COPELAND
Veterans Law Judge, Board of Veterans' Appeals


Department of Veterans Affairs