Citation Nr: 1325562 Decision Date: 08/13/13 Archive Date: 08/16/13 DOCKET NO. 10-18 249A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUE Entitlement to service connection for a skin disorder, to include soft tissue sarcoma or lipomas. REPRESENTATION Appellant represented by: Stephen J. Wenger, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L. Kirscher Strauss, Counsel INTRODUCTION The Veteran served on active duty from August 1965 to May 1969. His DD 214 reflects service in Vietnam from May 1968 to May 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania, which in pertinent part, denied entitlement to service connection for soft tissue sarcoma. The Board notes that the United States Court of Appeals for Veterans Claims (Court) has held that, although an appellant's claim identified a certain disorder without more, it cannot be a claim limited only to that diagnosis, but must rather be considered a claim for any disability that may reasonably be encompassed by several factors, including the claimant's description of the claim, the symptoms the claimant describes, and the information the claimant submits or that VA obtains in support of the claim. The Court reasoned that an appellant does not file a claim to receive benefits only for a particular diagnosis, but for the affliction (symptoms) his condition, however described, causes him. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Here, although the Veteran initially characterized his claim as one for service connection for soft tissue sarcoma due to exposure to Agent Orange, he has also asserted that he has "lumps" all over his body due to exposure to herbicides and due to chloracne, which he had previously claimed as due to exposure to herbicides. (His previous claim for chloracne was denied in a March 2008 rating decision because the evidence did not show that he had chloracne.) In an April 2012 rating decision, the RO denied reopening the claim of service connection for chloracne, denied reopening the claim of service connection for soft tissue sarcoma, and denied service connection for lipomas. The RO notified the Veteran and his attorney of the decision in a July 2012 letter. In August 2012 correspondence received on a VA Form 9, Appeal to Board of Veterans' Appeals, the Veteran expressed disagreement with the denial of service connection for lipomas. However, the Board notes that the issue of entitlement to service connection for soft tissue sarcoma was already on appeal when the RO issued the April 2012 rating decision and that the Veteran's communications regarding the claim for soft tissue sarcoma regularly referred to his complaints of lumps on his body. Moreover, in both the April 2012 statement of the case and the July 2012 supplemental statement of the case, the RO discussed lumps or lipomas when adjudicating the issue of service connection for soft tissue sarcoma. Accordingly, the Board finds that, pursuant to Clemons, supra, and the RO's actions in addressing the Veteran's symptoms of lumps or lipomas in connection with the claim for soft tissue sarcoma, the Veteran's claim of service connection is more accurately classified as one for a skin disorder other than chloracne, to include soft tissue sarcoma and lipomas. See Clemons, 23 Vet. App. 1 (2009). In other words, because the claim of service connection for chloracne had previously been denied, and because the Veteran did not express disagreement with the April 2012 rating decision that denied reopening the claim of service connection for chloracne, that issue is not before the Board. (The references in this decision to skin disability should be taken to mean any skin disability other than chloracne.) In March 2013, the Veteran testified at a hearing conducted at VA's Central Office in Washington, DC before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Virtual VA claims file. The Veteran's attorney submitted a revised medical opinion from a Dr. M. Mudrick in April 2013. Waivers of RO jurisdiction for March and April 2013 medical opinions were received in written statements dated in March and April 2013, respectively, which are included in the record. The Board accepts this evidence for inclusion in the record on appeal. See 38 C.F.R. § 20.1304 (2012). FINDINGS OF FACT 1. The Veteran does not have a soft tissue sarcoma. 2. The Veteran's lipomas or angiolipomas, which were first manifested decades after separation from service, are not related to military service, including in-service exposure to herbicides. CONCLUSION OF LAW The Veteran does not have a skin disability, to include soft tissue sarcoma or lipomas, that is the result of disease or injury incurred in or aggravated by active military service. 38 C.F.R. §§ 1110, 1116, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. The Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 and 5126 (West 2002 & Supp. 2013) and 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012), describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, the issuance of a late notice may be cured by re-adjudication. In this case, in November and December 2009 letters the RO provided notice to the Veteran regarding what information and evidence was needed to substantiate his claim for service connection, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The November 2009 letter advised him that the RO may consider that his claimed skin disorder is associated with dioxin exposure if the Veteran sends scientific or medical evidence showing that the claimed condition is medically associated with dioxin exposures. The letter added that if a doctor expresses an opinion regarding a relationship between a claimed skin condition and dioxin exposure, the doctor should provide literature that supports the opinion, such as scientific or medical journal articles that support the opinion that the exposure is related to the currently diagnosed condition. The December 2009 letter requested evidence showing when the claimed disability began. The letters also advised him of how disability evaluations and effective dates are assigned and the type of evidence that impacts those determinations. The case was last adjudicated in July 2012. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran, including his service treatment and personnel records, post-service private treatment records, VA examination and medical opinion reports, private medical opinion reports, hearing testimony, and lay statements. VA has considered and complied with the VCAA provisions discussed above. The Veteran was notified and aware of the evidence needed to substantiate the claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between the Veteran and VA in obtaining such evidence. The Veteran was an active participant in the claims process by submitting evidence and argument, including from his attorney. Therefore, he was provided with a meaningful opportunity to participate in the claims process. II. Analysis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). In addition, service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a present disability, there must be: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Holton v. Shinseki, 557 F.3d 1362 (2009). 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. If the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). In addition, certain diseases associated with exposure to herbicide agents may be presumed to have been incurred in service even though there is no evidence of the disease in service, provided the requirements of 38 C.F.R. § 3.307(a)(6) (2012) are met. See 38 C.F.R. § 3.309(e) (2012). The term "herbicide agent" means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the Vietnam era. Diseases affecting the skin for which service connection may be presumed to be due to an association with herbicide agents include soft tissue sarcoma, chloracne or other acneform disease consistent with chloracne, or porphyria cutanea tarda. An inclusive list defining the term soft tissue sarcoma is found at 38 C.F.R. § 3.309(e), Note 1. In general, for service connection to be granted for one of these diseases, it must be manifested to a degree of 10 percent or more at any time after service. However, chloracne or other acneform disease consistent with chloracne and porphyria cutanea tarda must be manifest to a degree of 10 percent within one year after the last date on which the veteran performed active military, naval, or air service in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. See 38 C.F.R. § 3.307(a)(6)(ii). A veteran who served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, will be presumed to have been exposed during such service to an herbicide agent unless there is affirmative evidence to the contrary. Id. The lists of diseases that are presumed to be related, or due to, herbicide exposure are updated by the Secretary based on information provided by the National Academy of Sciences. The Secretary of VA has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Determinations Concerning Illnesses Discussed in National Academy of Sciences Report: Veterans and Agent Orange: Update 2010, 77 Fed. Reg. 47,924 -47,928 (Aug. 10, 2012). Even if the Veteran cannot establish service connection for his claimed skin disorder on a presumptive basis, he is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). The Veteran's service treatment records were silent for complaints, findings, or diagnosis of a chronic skin problem. The records documented tinea [cruris] in June and October 1968, pubic lice in March 1969, and venereal warts in April 1969. In a September 1968 separation report of medical history, the Veteran denied currently or ever having skin diseases. On separation examination in September 1968, clinical evaluation of the skin was reported as normal. Photocopies of post-service private treatment records from D. Mudrick, M.D. and M. Mudrick, M.D., including reports from Crozer Chester Medical Center, dated from August 1969 to February 2009 were provided by the Veteran and are associated with the claims file. In October 1971, the Veteran reported open sores on his leg. In September 1983, he reported a rash during warm weather since Vietnam. The assessment was chronic tinea cruris of the groin. In June 1984, he complained of a lump beneath his left ear that was sore to the touch. In March 1992, he stated that he had a black lesion to the right bridge of his nose for one year that occasionally bled. The assessment was probable benign lesion. An April 1992 pathology report addressed to Dr. D. Mudrick indicated that the pathological diagnosis from the specimen taken from below the right eye was consistent with mild actinic keratosis. Although the entire pathology report is typed, including the pathologist's signature, "choracne" [sic] is hand-written underneath the listed pathological diagnosis of mild actinic keratosis. In November 1999, he complained of left mid-back pain. On examination, a half-inch distinct lipoma of the posterior thorax was noted. In May 2001, the Veteran described a lesion on his left hand. The assessment was benign tumor left hand. The June 2001 pathology report identified thrombosed vessel showing organization. In June 2002, he had no complaints, but several subcutaneous nodules were present on evaluation. In March 2005, he reported that he had a cyst removed from his jaw. During an August 2006 check-up, he reported lumps on his entire body, multiple cystic feeling lesions, and a history of exposure to Agent Orange. The assessment was lipoma right upper arm, sebaceous cysts, Agent Orange exposure. A mass on the right upper arm was excised in November 2006. In congressional correspondence received by VA in November 2009, the Veteran stated that he filed a claim for chloracne in 2007 and the condition had resulted in lumps all over his body. He indicated that he gets a lump removed every two or three years and biopsied to check for cancer. Later in November 2009, the Veteran's claim of service connection for soft tissue sarcoma was received. In December 2009 correspondence, he asserted that his civilian medical records list evidence of soft tissue sarcoma. The Veteran was afforded a VA peripheral nerves examination in December 2009. He stated that he developed some spots on his chest and back shortly after Vietnam and was given some creams. He reported that these spots developed into lumps and he went to see Dr. Mudrick. He indicated that he had some biopsies, but was unable to recall whether he was specifically diagnosed with soft tissue sarcoma. The examiner indicated that the claims file was not available for review, so she was unable to diagnose soft tissue sarcoma without any clinical records. In congressional correspondence received by VA in March 2010, the Veteran stated that he developed skin spots from exposure to Agent Orange and later lumps appeared. He reported that "lumps are fat tissue disruption (soft tissue sarcoma)." He indicated that he had had three biopsies performed to check for cancer and the results were all negative. In correspondence sent to the RO in support of his claim for soft tissue sarcoma in March 2010, the Veteran included VA Internet publications regarding Veterans' Diseases Associated with Agent Orange Exposure and regarding soft tissue sarcoma, specifically. The information explains that chloracne or similar acneform disease is a "skin condition that occurs soon after dioxin exposure and looks like common acne seen in teenagers." The publication describes soft tissue sarcoma as a "group of different types of cancers in body tissues such as muscle, fat, blood and lymph vessels, and connective tissues." Porphyria cutanea tarda is also described as a "disorder characterized by liver dysfunction and by thinning and blistering of the skin in sun-exposed areas." In additional congressional correspondence dated in March 2010, the Veteran questioned how VA knows that "Agent Orange infected thousands of military veterans...and yet deny [sic] service connected claims." In May 2010 the Veteran indicated that he had more than 20 growth lumps on his body. The Veteran was afforded a VA skin diseases examination in January 2011. He stated that he indeed had not been diagnosed with soft tissue sarcoma or skin cancer and he had not had a previous diagnosis of chloracne. However, he did have a history of exposure to Agent Orange in Vietnam and reported the onset of multiple subcutaneous lumps on his body since the late 1970s. He described the lumps as a progressive condition because he continued to form new lumps, some of which can be sore if bumped. He related that past treatment had been excision of several of these masses and the pathology report showed lipoma. He denied any other treatment. Following a review of the claims file and physical examination, the diagnosis was multiple lipomas; no history or evidence on examination of soft tissue sarcoma or chloracne. The examiner opined that the Veteran's current multiple lipomas were not caused by or a result of Agent Orange exposure. She explained that lipomas are a common skin condition and she was not aware of any evidence that links their formation to Agent Orange exposure. The examiner added that the Veteran had no evidence of chloracne, which has been linked with Agent Orange exposure. During the March 2013 hearing, the Veteran's attorney framed the issue on appeal a claim for lumps, diagnosed as lipomas. He related the Veteran's reported history of developing some spots on his skin and filing an initial claim for chloracne. He asserted that the lumps developed after that, but were not properly diagnosed. He explained that the Veteran self-diagnosed soft tissue sarcoma, but it was clear that his skin disorder did not appear to be soft tissue sarcoma. He acknowledged that lipomas are not among the list of presumptive diseases associated with exposure to Agent Orange, but submitted a medical opinion in support of the Veteran's claim. He also asserted that based on his research, the Veteran's lumps or lipomas are coagulated fatty tissue in the body caused by exposure to Agent Orange. The attorney added that, anecdotally, he had seen lipomas quite often in Vietnam veterans. The Veteran testified that he first noticed skin spots, which caused his discoloration across his chest and down his back with a rash between it all, while he was in Vietnam and was told at the dispensary that the spots were caused by the monsoon and tropical heat. He stated that after separation from service, he went to Dr. [D.] Mudrick in 1969 for treatment and a rash in his groin area, and he received topical cream. He testified that the spots remained for at least 10 or 15 years and went away. Then, he developed lumps on his body and had a couple, one on his hand and one on his arm, biopsied, but none was diagnosed as cancer. He reported that Dr. [M.] Mudrick diagnosed the lumps as lipomas and indicated that the lumps were the same problem, but different sizes. The Veteran displayed some of his lumps, which were described for the record as approximately marble size and subcutaneous. In March 2013, the Veteran waived AOJ consideration of a March 2013 medical opinion from M. Mudrick, M.D., and additional argument by his attorney. Dr. Mudrick indicated that the Veteran had been a patient in the office since 1969 and for the past two decades [since approximately 1993] he ha[d] complained intermittently, though increasingly, about the appearance of multiple subcutaneous nodules. Prior to this time, there [were] no complaints of nodules. He attributes the nodules to his exposure to the dioxin containing herbicide, Agent Orange. [The Veteran] ha[d] twice been sent for surgical consultation. The first consultation occurred in September [] 2006 and one of the nodules was excised. Pathology revealed the nodule to be an angiolipoma. While no other nodules have been excised, their similar size, location beneath the skin, and feel strongly suggest that they, too, are angiolipomas or lipomas. While [VA] has not listed angiolipomas as causally related to Agent Orange exposure, the timing of the nodules['] appearance and other anecdotal cases certainly support the possibility that these nodules could be due to [the Veteran's] Agent Orange exposure. In a written brief received in March 2013 with the private medical opinion, the Veteran's attorney summarized that the Veteran had described his skin disability as chloracne or soft tissue sarcoma, but the disease had not been diagnosed properly. He stated that the Veteran appears to have a form of lipoma, which he acknowledged is not among the list of presumptive diseases associated with Agent Orange exposure, and that "[t]his disease has been found in hundreds of veterans who served" in Vietnam and were exposed to Agent orange. The attorney asserted that based on Dr. M. Mudrick's medical opinion, service connection should be granted, or the claim should be remanded for further development. The attorney believed that no medical opinion had been offered by the RO regarding lipoma other than that it was not on the presumptive list. The attorney also asserted that in the absence of medical proof that the Veteran's lipomas were not aggravated or caused by military service, service connection for lipomas must be awarded. The Veteran and his attorney were advised during the hearing that clarification from Dr. M. Mudrick regarding any relationship between the Veteran's previous spots and his later lipomas, or studies regarding the etiology of lipomas, to include exposure to Agent Orange, would help to support the claim. Following the hearing, the Veteran's attorney submitted a revised medical opinion from Dr. M. Mudrick dated in April 2013 that was identical to the prior opinion, except for two changes. In the new opinion, Dr. M. Mudrick indicated that she was familiar with the Veteran's service record, including his Agent Orange exposure. She also opined that "the timing of the appearance of the nodules and other anecdotal cases support the likelihood that the nodules are, to a reasonable degree of medical certainty, due to [the Veteran's] Agent Orange exposure." Having reviewed the entire claims file, the Board finds that service connection for disability of the skin, to include soft tissue sarcoma or lipomas, is not warranted. The Board acknowledges that the Veteran is competent to provide lay evidence of reporting his current symptoms of lumps and that he has experienced skin problems, including discoloration and rashes prior to developing lumps. See Charles v. Principi, 16 Vet. App. 370, 374 (2002); Layno v. Brown, 6 Vet. App. 465, 469 (1994); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Further, a claimant is generally competent to introduce lay testimony of observable symptoms of disability and continuity of such symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although the Court and Federal Circuit have addressed the circumstances where lay evidence can/must be considered, both have also addressed where the Board may make findings that the lay statements are beyond the competence of the giver, or that the statements are not credible or the giver of the lay evidence is mistaken. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007); Jandreau, 492 F.3d at 1377 n.4 (sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer). As in this case, neither the Veteran nor his attorney is competent to state that the Veteran's disability of the skin is medically related to exposure to herbicides during military service in Vietnam or that his diagnosed lipomas or angiolipomas are medically related to his previous skin spots described as discoloration with a rash because diagnosing a particular skin disorder and determining the etiology of such requires some degree of medical expertise, and in some cases diagnostic testing such as a biopsy. Neither has shown that he possesses a degree of medical expertise necessary to diagnose skin disorders generally or to identify the etiology of the Veteran's current skin disability, diagnosed as lipomas. Despite the Veteran's assertions that his claimed skin disability manifested by subcutaneous lumps is associated with exposure to herbicides, lipomas, in fact, are not included in the list of diseases associated with exposure to herbicides. See 38 U.S.C.A. § 1116 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309. The only medical opinions to address whether the Veteran's lipomas are related to exposure to herbicides are from the January 2011 VA examiner and from Dr. M. Mudrick in March and April 2013. The Board finds that the January 2011 medical opinion by the VA examiner is persuasive and probative evidence against the claim for service connection because it was based on a review of the claims file and physical examination and was supported by an articulated medical explanation that is consistent with the remaining record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value to a medical opinion). Here, the examiner explained that lipomas are a common skin condition and there was no evidence that links their formation to Agent Orange exposure. In comparison, while Dr. M. Mudrick plainly has an extensive history as the Veteran's physician and knowledge of his exposure to Agent Orange during his service in Vietnam, the Board finds unpersuasive her opinion that the Veteran's angiolipomas are due to Agent Orange exposure. Dr. Mudrick believed that the "timing of the appearance of the nodules and other anecdotal cases" supported the likelihood that the nodules were, to a reasonable degree of medical certainty, due to exposure to Agent Orange. Unfortunately, she did not explain how the timing of the onset of lipomas, which she identified as approximately 1993, made it likely or reasonably certain that they were due to Agent Orange exposure 24 years earlier. Nor did she elaborate how "other anecdotal cases" support the conclusion that the Veteran's lipomas are due to Agent Orange exposure. For example, she did not provide information regarding how many patients exposed to Agent Orange she has treated; the approximate incidence of lipomas in non-exposed versus exposed patients, even in her own patient population; or other factors that would cause her to conclude that a common, benign skin disorder is associated with exposure to Agent Orange. In other words, Dr. Mudrick did not adequately explain what led to her conclusion or cite any medical studies or literature in support of her conclusion. In addition, the Board finds the January 2011 VA examiner's medical opinion more persuasive than the opinions of Dr. Mudrick because the VA examiner's rationale reflects that she considered the existence of medical literature or studies, but stated that she was not aware of any evidence to support the proposition that formation of lipomas can be related to Agent Orange exposure. The Board finds that the VA examiner's medical opinion is adequately supported and consistent with the record. In summary, lipomas are not included in the list of diseases associated with exposure to herbicides and the Board has not received competent and persuasive medical evidence sufficient to conclude otherwise. Moreover, the evidence does not reflect that the Veteran has a current skin disability that has been recognized by VA as associated with exposure to Agent Orange, including soft tissue sarcoma, chloracne, or porphyria cutanea tarda. In fact, he acknowledges that he has never been diagnosed with a skin cancer. His description of his current skin disability manifested by subcutaneous lumps is inconsistent with the description of chloracne that he located and submitted from the VA website in March 2010, and he has never claimed entitlement to porphyria cutanea tarda. Therefore, entitlement to service connection for a skin disability, including the current lipomas, is not warranted on a presumptive basis due to herbicide exposure. 38 C.F.R. §§ 3.307, 3.309. In reviewing the claims file for a continuity of symptomatology since military service, the Board emphasizes that service treatment records do not reflect, nor does the Veteran contend, that he experienced lumps during military service or for many years thereafter. The one exception to a reported onset of lumps many years after service was during his VA examination in January 2011 when he reported the onset of multiple subcutaneous lumps on his body since the late 1970s. The Board finds that this statement regarding the onset of lumps is inconsistent with the medical evidence of record and his other statements, including his testimony given under oath that the lumps began after previous spots or a rash resolved 10 or 15 years after service. As a result, the statement regarding an onset of lumps in the late 1970s is not credible. The post-service medical evidence of record reflects that a lipoma was first diagnosed in November 1999, more than 30 years after separation from service, or around 1993 according Dr. M. Mudrick's recollection, still more than two decades after separation from service. The passage of many years between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). Parenthetically, the Board acknowledges that the January 2011 VA examiner did not provide a medical opinion regarding a direct relationship between the current lipomas and military service. However, the Board declines to obtain a medical nexus opinion with respect to the issue of entitlement to service connection on a direct basis, because there is no evidence of subcutaneous lumps in service, any contention that they were present during service, or any credible assertion that they manifested earlier than at least two decades after service. See 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006) (describing VA's duty to provide medical examinations). To the extent that the spots the Veteran reportedly experienced during military service may have been prodromal signs or precursors of his current lipomas, the Veteran and his attorney were advised to seek an additional medical opinion or more information from Dr. M. Mudrick to address this assertion. However, the revised medical opinion did not identify any link between these distinct skin manifestations, and the medical evidence of record and the Veteran's statements and testimony in support of his claim reflect that he has consistently described different manifestations of skin problems. Therefore, VA is not required to obtain an additional medical opinion to address direct service connection. As a final matter, citing Wagner v. Principi, 370 F.3d 1089, 1093-04 [sic] (Fed. Cir. 2004), the Veteran's attorney asserts that in the absence of medical proof that the Veteran's lipoma disability was not aggravated or caused by military service, service connection must be warranted. The Board notes that Wagner addresses what VA must show by clear and unmistakable evidence in order to rebut the presumption of soundness at service entry. Wagner, 370 F.3d at 1096. The Veteran's case does not involve a question of a preexisting skin disability; he claims that his multiple lipomas, which manifested decades after service, are due to exposure to Agent Orange. Therefore, Wagner is inapplicable in this case and does not provide a basis for granting the claim. For all the foregoing reasons, the Board finds that service connection for disability of the skin, to include soft tissue sarcoma or lipomas, is not warranted. In reaching the conclusion to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim and the evidence is not in relative equipoise, that doctrine is not helpful to the Veteran. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for a skin disability, to include soft tissue sarcoma or lipomas, is denied. ________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs