Citation Nr: 1328212 Decision Date: 09/04/13 Archive Date: 09/10/13 DOCKET NO. 05-28 015 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a brain tumor, to include as a result of herbicide exposure. 2. Entitlement to service connection for a skin disability, to include as a result of herbicide exposure. ATTORNEY FOR THE BOARD J. L. Prichard, Counsel INTRODUCTION The Veteran served on active duty from May 1967 to April 1970, including service in the Republic of Vietnam. These matters come before the Board of Veterans' Appeals (Board) from a February 2009 rating decision of the Department of Veterans' Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In the February 2009 decision, the RO, among other actions, denied entitlement to service connection for a brain tumor with associated memory loss, and denied the Veteran's petition to reopen his previously denied claim for service connection for a skin rash as new and material evidence had not been submitted. These issues were among those previously before the Board in February 2010, when they were remanded for additional development. They were also among the issues returned to the Board in July 2012, when a remand was once more required for these final two claims. All requested development has now been completed, and the appeal was returned to the Board for further consideration in May 2013. The Board sought an additional medical opinion from the Veterans Health Administration (VHA), which was received in June 2013. The Veteran was provided with a copy of this opinion and provided an opportunity to respond, but did not respond within the allotted time. The Board will proceed with consideration of this matter. Service connection for a rash associated with herbicide exposure was denied by the RO in March 2003. In August 2003, the Veteran submitted a statement from his spouse, which included her report that the Veteran had a rash that had started in Vietnam and had continued to flare up ever since. The submission was received prior to the expiration of the appellate period for this RO determination and contained new and material evidence pertaining to the claim. See 38 C.F.R. § 3.156(b) (2011). New and material evidence received during the appeal period after notice of the rating decision, renders the decision non-final and pending until it is readjudicated. Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011) (. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. The Veteran was previously represented by a private attorney. In January 2013, prior to the certification of the Veteran's appeal to the Board, the attorney withdrew as the Veteran's representative. Her withdrawal letter shows that a copy of this withdrawal was provided to the Veteran. See 38 C.F.R. § 20.608(a). The Veteran has not appointed a new representative in this matter. FINDINGS OF FACT 1. There is no relationship between the Veteran's current brain tumor and a disease or injury in active service, to include herbicide exposure during active service. 2. The Veteran's current skin disabilities are not related to a disease or injury in active service, including herbicide exposure or skin conditions treated during active service. CONCLUSIONS OF LAW 1. A brain tumor was not incurred due to active service, nor may it be presumed to have been incurred due to herbicide exposure during active service. 38 U.S.C.A. §§ 1110, 1112, 1116, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309(a)(e) (2012). 2. A chronic skin disability was not incurred due to active service, nor may it be presumed to have been incurred due to herbicide exposure during active service. 38 U.S.C.A. §§ 1110, 1112, 1116; 38 C.F.R. §§ 3.303, 3.307, 3.309(e). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002); C.F.R. § 3.159(b)(1) (2012). VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Court has also 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 service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In this case, the Veteran was provided with a letter in August 2008 that contained all of the notification required by 38 U.S.C.A. § 5103 and 38 C.F.R. § 3.159, as defined by Dingess and Pelegrini. This letter was provided to the Veteran prior to the initial adjudication of his claims. The duty to notify has been met. The duty to assist has also been satisfied. The Veteran's service treatment records have been obtained. Private records and VA treatment records have been obtained. Records have also been obtained from the Social Security Administration (SSA). He was afforded appropriate VA examinations, and relevant opinions have been obtained from the examiners after a review of the claims folder. Previous examinations yielded inadequate opinions. In its July 2012 remand, the Board sought to afford the Veteran a new skin examination and obtain clarification from the examiner who had provided an opinion regarding the brain tumor claim. VA subsequently provided a skin examination, which as discussed below, yielded an adequate medical opinion. The clarification requested with regard to the brain tumor claim was inadequate. The Board remedied this deficiency by obtaining an adequate opinion from the VHA. There is no indication that there is any relevant evidence outstanding in these claims, and the Board will proceed with consideration of the Veteran's appeal. Service Connection The Veteran contends that he has developed a brain tumor with memory loss and a skin disability as a result of exposure to herbicides such as Agent Orange during his service in Vietnam. The Veteran argues that he has experienced memory problems ever since discharge from service, which he believes were caused by a brain tumor that was present since service but remained undiagnosed until 2008. He believes that medical studies have associated brain tumors to Agent Orange. The Veteran further notes that he was treated for a skin rash during service. He argues that his rash was due to herbicides, that he has had periodic outbreaks since service, and that the rash in service is the same as the rash for which he currently receives treatment. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. This method may be used only for the chronic diseases noted in 38 C.F.R. § 3.309. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As the list of chronic diseases includes tumors of the brain, then continuity of symptomatology must be considered. Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997) In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. Nieves-Rodriguez, 22 Vet. App. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical profession." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence." A lay person is competent in certain situations to provide a diagnosis of a simple condition such as tinnitus, hand pain, and shortness of breath, the Veteran is not competent to provide evidence as to more complex medical questions, as is the case here. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). If a brain tumor becomes manifest to a degree of 10 percent within one year of separation from active service, then it is presumed to have been incurred during active service, even though there is no evidence of a psychosis during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309, 3.384. The Veteran believes that his disabilities are the result of exposure to herbicides such as Agent Orange during service. A veteran who, during active military service, served in Vietnam during the period beginning in January 1962 and ending in May 1975 is presumed to have been exposed to herbicides. 38 C.F.R. §§ 3.307, 3.309. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the Vietnam era. "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307. If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected even though there is no record of such disease during service; chloracne or other acneform disease consistent with chloracne, Type 2 diabetes, Hodgkin's disease, ischemic heart disease, all chronic B-cell leukemias, multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx or trachea), and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). The term "soft-tissue sarcoma" includes adult fibrosarcoma, dermatofibrosarcoma protuberans, malignant fibrous histiocytoma, liposarcoma, leiomyosarcoma, epithelioid leiomyosarcoma (malignant leiomyoblastoma), rhabdomyosarcoma, ectomesenchymoma, angiosarcoma (hemangiosarcoma and lymphangiosarcoma), proliferating (systemic) angioendotheliomatosis, malignant glomus tumor, malignant hemangiopericytoma, synovial sarcoma (malignant synovioma), malignant giant cell tumor of the tendon sheath, malignant schwannoma, including malignant schwannoma with rhabdomyoblastic differentiation (malignant Triton tumor), glandular and epithelioid malignant schwannomas, malignant mesenchymoma, malignant granular cell tumor, alveolar soft part sarcoma, epithelioid sarcoma, clear cell sarcoma of tendons and aponeuroses, extraskeletal Ewing's sarcoma, congenital and infantile fibrosarcoma, and malignant ganglioneuroma. 38 C.F.R. § 3.309(e). For the purposes of this section, 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. The diseases listed at § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year, after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. Notwithstanding the foregoing presumption provisions, a claimant is not precluded from establishing service connection with proof of direct causation. Stefl; see Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). 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. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d). A disorder may be service connected if the evidence of record, regardless of its date, shows that the veteran had a chronic disorder in service or during an applicable presumptive period, and that the veteran still has such a disorder. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 494-95 (1997). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). Brain Tumor In addition to contending that his brain tumor is the result of Agent Orange exposure, he contends that the tumor has been present since he was in active service. He reports chronic memory problems since service, and argues that as the tumor is located in the area of the brain that controls memory, it must have been the tumor that was causing these problems from the very beginning. Based on the Veteran's service in Vietnam, he is presumed to have been exposed to herbicides such as Agent Orange. However, it should also be noted that the Court has found that mere exposure to Agent Orange, without something more, is not a compensable occurrence under governing law. Winsett v. West, 11 Vet. App. 420 (1998). See also 38 U.S.C.A. § 1116; 38 C.F.R. § 3.309(e). The medical evidence clearly shows that the Veteran has a current diagnosis of a brain tumor. He complained of tremors in his upper extremities following a 2008 back surgery, and the tumor was first identified on a computed tomography scan in February 2008. Other records dated in 2008 show that the tumor was assessed as parafalcine meningioma, and was determined to be benign. As the Veteran has a current diagnosis of a brain tumor, the first requirement for service connection has been met. However, the evidence must still show that the current brain tumor. His presumed herbicide exposure and his competent and credible reports of memory difficulties satisfy the requirement for an in-service event. The remaining question is whether there is a link between the current brain tumor and service. The Veteran's brain tumor is diagnosed as a parafalcine meningioma. This disability is not recognized as a disease which is presumed to be the result of herbicide exposure, and service connection cannot be awarded on a presumptive basis due to herbicide exposure. 38 C.F.R. § 3.309(e). There is no competent evidence otherwise linking the brain tumor to herbicide exposure. Brain tumors are recognized as a presumptive diseases under 38 C.F.R. § 3.309(a). The service treatment records are completely negative for complaints or diagnoses relating to a brain tumor. There is also no evidence of complaints or diagnoses of a brain tumor during the first year after discharge from service. The Veteran could also establish service connection for the brain tumor with evidence of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). However, the preponderance of the evidence is against direct causation. The Veteran contends that he began to experience memory problems in the early 1970s. In addition, the May 2008 statement from the Veteran's wife notes that he was changed after he returned from Vietnam. She states that he had increasing memory loss dating from the early 1970s. A May 2008 statement from the Veteran's sister-in-law also notes that he had been experiencing memory loss for many years. A March 2008 opinion from the Veteran's private doctor states that the Veteran's memory problems were most likely secondary to meningioma, which might be secondary to Agent Orange exposure. This doctor repeated the same opinion almost word for word in September 2008. This opinion is of limited probative value because the physician did not provide a rationale for the opinions. In contrast is the opinion of the VA examiners. The Veteran underwent VA examination in November 2010. The claims folder was reviewed by the examiner. The Veteran was first found to have meningioma after he presented with tremors in February 2008. He had undergone surgery for resection of the meningioma and was treated with medication. His memory had been stabilized. The examiner opined it was less likely than not that the Veteran's brain tumor was related to his in-service herbicide exposure or any other disease or injury in service. The rationale for this opinion was that there was no evidence of a brain tumor or symptoms of a brain tumor in the service treatment records. Also, meningioma was not one of the conditions that have been associated with Agent Orange exposure. This opinion is of little probative value, because the examiner failed to consider the implications of the Veteran's report of memory problems beginning in service. The claims folder was returned to the November 2010 examiner in February 2013, and she was requested to consider the reports of memory problems. The claims folder was again reviewed, and the examiner again found that it was less likely than not that the brain tumor was incurred in or caused by active service. She stated that the reports of the Veteran and his spouse discussing the onset, nature and continuity of symptomatology were considered in reaching her opinion. T The examiner noted that a review of literature disclosed that there was a slow rate of growth for meningioma, and that the usual presentation was due to mass effect in the form of seizures. Neither the Veteran nor the record documents any neurologic events that would have triggered further imaging until 2008 to 2009. The examiner then reviewed at length a study on the natural rate of growth of meningiomas. It was noted that the Veteran did not present with symptoms which were suspicious for a brain tumor until 38 years after Agent Orange exposure. Based on the natural history described in the study, meningioma was less likely than not a condition that began 38 years prior to diagnosis based on natural history data. Therefore, it was less likely than not that the current brain tumor was related to his in-service herbicide exposure or any other disease or injury in service. The supplemental opinion was also inadequate and of limited probative value, because the physician again failed to consider the reports of memory loss dating to service. Finally, the claims folder was forwarded to the VHA, and an expert medical opinion was obtained in June 2013. The examiner reviewed all five volumes of the Veteran's claims folder. He further indicated that he conducted an internet search for certain aspects of the requested opinions, and that he had over 20 years of practice as a Board Certified Neurologic Surgeon, and that this combined to form the bases of his opinions. The examiner opined that there was nearly a zero percent chance that the memory loss reported by the Veteran as early as 1970 was related to the meningioma identified in 2008. He said that based on his experience with several hundred meningioma patients, he strongly stated that memory loss would not be a symptom of the right anterior hemisphere meningioma of 3.22 millimeters that was found in 2008. The size and right sided position of the tumor were the relevant factors. The examiner further noted that the tremors experienced by the Veteran in 2008 were not likely to be related to the meningioma, even though they had led to its discovery. The examiner characterized the meningioma as an asymptomatic incidental finding in 2008. He added that even if one assumed that the 2008 memory loss was due to the tumor, there was a very near zero likelihood it would have been the source of the 1970 memory loss. He explained that meningiomas are very slow growing so that, if present in 1970, it would have been too small to cause a problem. The June 2013 examiner further opined that it was not at least as likely as not that meningioma was caused by herbicide exposure. It was at best a very small possibility that herbicides had anything to do with the meningioma developing. The examiner noted that the best studies had determined that there was no connection, and while two or three other studies suggested there might be a weak connection, these were not statistically strong. The examiner considered the March and September 2008 letters from the private doctor. The June 2013 examiner noted the use of the word "might" in the private opinion, as well as the lack of citation to any research that would support this conclusion. The June 2013 VHA opinion is unique in that it reflects consideration of an accurate and complete history, including the Veteran's reports of symptoms. The opinion is definitive and is supported by detailed reasons based on the record and medical and scientific knowledge. The examiner is a highly qualified Board certified physician who has treated hundreds of meningioma patients. Hence, it is the most probative opinion as to whether the current brain tumor had its onset in service, or is otherwise related to a disease or injury in service. Nieves-Rodriguez v. Shinseki. The Veteran is competent to report memory problems and his reports are credible. He would not; however, be competent to say that the memory loss was a manifestation of a brain tumor. As this case demonstrates, brain tumors are discovered through diagnostic testing and it would require medical expertise to attribute specific symptoms to the brain tumor as opposed to other causes. The analysis involves consideration of the location and size of the tumor, matters, which a lay person would not be competent to determine. The Board notes that the Veteran has also submitted an October 2010 letter in which he quotes from, and cites to, several studies pertaining to the relationship between herbicides and brain tumors. However, the majority of these studies are concerned with malignant tumors, and tumors other than meningiomas. As such, these are not relevant to his claim. The Veteran does quote from an article on meningiomas from the Mayfield & Spine Institute, which states that while the cause of meningiomas is not certain, most scientists agree that they are due to a malformed chromosome. This does not support the theory that the Veteran's meningioma was due to herbicide exposure. He does cite to research at Cornell University in which a particular chemical was shown to cause chromosome damage. He also cited studies suggesting the herbicides could migrate to brain tissue and cause brain tumors. Some of these studies refer specifically to malignant brain tumors, which have not been demonstrated in the Veteran's case. The Veteran cites other studies as referring only to "brain tumors." The studies also focus on the possible link between pesticides and brain tumors rather than herbicides. Most importantly, the VHA expert reviewed the current scientific literature, as well as the Veteran's summary, and interpreted current literature as showing it is less likely than not that the meningioma is linked to herbicide exposure. In summary, the most probative evidence is against a nexus between the current brain tumor and active service. Reasonable doubt does not arise and the claim is denied. 38 U.S.C.A. § 5107(b) (West 2002). Skin Disability The Veteran notes that he was treated for a skin disability during service, and argues that his current disability is a continuation of the disability for which he was treated in service. The Veteran's service treatment records show that he was seen for a rash that was diagnosed as pityriasis rosea in July 1968. In August 1968 he was seen for areas of leukoderma over his trunk and arms. He had some lesions consistent with tinea versicolor, but most areas were not clinically consistent and appeared more like hyperpigmentation. The impression was leukoderma with an unknown etiology. January 1969 service treatment records show that the Veteran was seen for several different complaints. The examiner indicated that the rash was improving. The April 1970 service discharge examination reportedly found that the Veteran's skin was normal. He denied a history of skin diseases on the Report of Medical History he completed at this time. The August 2003 statement from the Veteran's spouse reveals that he was said to have a rash that started flaring up in Vietnam and continued to do so. In a March 2010 letter the Veteran's spouse noted that the Veteran had a rash that came and went. The Veteran was afforded a VA examination of his skin in February 2013. The claims folder was reviewed. The Veteran reported a history of scaly skin that had come and gone several times a month for many years. His only symptoms were intermittent flaking of the skin. He had been determined to have seborrheic dermatitis. The examiner opined that it was less likely than not that the Veteran's current skin disability was incurred in or caused by service. The rationale was that there was no association between pityriasis rosea noted in service and the seborrheic dermatitis with which the Veteran was currently diagnosed. A review of the literature was negative for any association between Agent Orange and seborrheic dermatitis. The dermatitis was a benign and easily treatable condition that was exceedingly common and not associated with environmental factors such as Agent Orange. The evidence demonstrates that the Veteran has a current diagnosis of a skin disability, and it follows that the first requirement for service connection has been met. The service treatment records, his reports, and the presumed herbicide exposure demonstrate an in-service disease or injury. However, the evidence must still show that his current skin disability is related to service. Seborrheic dermatitis is not one of the diseases that are presumed to be associated with herbicide exposure. The diagnoses noted or considered in service, which were pityriasis rosea, leukoderma, and tinea versicolor, are also not presumed to be associated with herbicide exposure. Service connection is not warranted on this basis. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.309(e). Similarly, the Veteran's seborrheic dermatitis, pityriasis rosea, leukoderma, and tinea versicolor are also not among the presumptive disabilities found at 38 C.F.R. § 3.309(a). It follows that continuity of symptomatology is not for consideration. As with the claim for a brain tumor, the Veteran can still establish service connection for his skin disability with evidence of direct causation. This includes evidence of direct causation due to herbicide exposure. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). However, the preponderance of the evidence is against direct causation. The February 2013 VA examiner noted that the Veteran's current skin disability, seborrheic dermatitis, was a different disability than the pityriasis rosea diagnosed during service. She found no relationship between seborrheic dermatitis and pityriasis rosea, and that the medical literature was also negative for evidence of a relationship between herbicide exposure and seborrheic dermatitis. This opinion was based on an accurate record and was supported by sufficient reasons based on the record and medical knowledge. Hence it is highly probative. Nieves-Rodriguez. The only opinion in contrast is that of the Veteran's. While the Veteran is competent to report his skin symptoms, he is not shown to be competent to make a diagnosis of this disability, or to opine in a complex matter such as the possible relationship between herbicides and seborrheic dermatitis. The Veteran and the others who provided lay statements in this case, lack the medical expertise to diagnose the specific skin conditions shown in service and currently, and they also lack the medical expertise that would be required to say that there was a relationship between the skin condition in service and that shown currently. The only competent medical opinion holds that there is no relationship between the Veteran's current seborrheic dermatitis and active service on any basis. Therefore, the preponderance of the evidence is against the Veteran's claim, and entitlement to service connection is not established. ORDER Entitlement to service connection for a brain tumor to include as a result of herbicide exposure is denied. Entitlement to service connection for a skin disability to include as a result of herbicide exposure is denied. ____________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs