Citation Nr: 1336879 Decision Date: 11/13/13 Archive Date: 11/26/13 DOCKET NO. 07-39 153 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE Entitlement to service connection for a thyroid disorder or Grave's disease, to include as a qualifying chronic disability under 38 C.F.R. § 3.317 or as due to radiation exposure and exposure to toxic chemicals. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Carole Kammel, Counsel INTRODUCTION The Veteran had active duty service from January 1990 to May 1990 and from November 1990 to July 1991, to include service in the Southwest Asia Theater of operations during the Gulf War. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a September 2006 rating decision of the St. Paul, Minnesota Regional Office (RO) of the Department of Veterans Affairs (VA). By this rating action, the RO denied service connection for a thyroid condition. The Veteran appealed this rating action to the Board. The Veteran was afforded a hearing before an Acting Veterans Law Judge (VLJ) in July 2010. That VLJ subsequently left the Board. The Veteran thereby requested a second hearing. In October 2012, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. Copies of both hearing transcripts have been associated with the claims files. The Board notes that after the issuance of a February 2013 Supplemental Statement of the Case (SSOC) additional VA treatment records (dated from January 2013 to October 2013) were uploaded to the Veteran's virtual claims folder. There is no indication that either the Veteran or his representative waived AOJ consideration of this evidence. However, because those records make no reference to the Veteran's Graves Disease (instead showing treatment for anxiety, depression, and a right shoulder disorder), they are not pertinent to the appeal. A remand to have the RO initially consider this evidence in the first instance is not necessary. 38 C.F.R. § 20.1304 (2013). In January 2013, the Board, in part, remanded the claim on appeal to the RO for additional development. The requested development has been completed and the matter has returned to the Board for additional appellate review. FINDING OF FACT A chronic thyroid or endocrine disorder was not shown in service or within a year of discharge; and, the preponderance of the evidence fails to establish that the Veteran's diagnosed non-malignant thyroid nodular disease (goiter) and Grave's disease is etiologically related to his active service, to include exposure to ionizing radiation or service in the Southwest Asia theater of operations. CONCLUSION OF LAW The Veteran's thyroid disorder, variously diagnosed as non-malignant thyroid nodular disease (goiter) and Grave's Disease, was not incurred in or aggravated by service, nor may they be presumed to have been incurred as a result of ionizing radiation or Gulf War exposure. 38 U.S.C.A. §§ 1110, 1117, 1118, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.311, 3.317 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a) (2013). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay 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); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via letters dated in April 2006 and February 2009, of the criteria for establishing service connection, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. He also was notified of how VA determines disability ratings and effective dates if service connection is awarded. These letter accordingly addressed all notice elements. Nothing more was required. VA also fulfilled its duty to assist the Veteran by obtaining all relevant evidence in support of the claim of and, therefore, appellate review may proceed without prejudicing him. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The RO obtained his service treatment and personnel records as well as identified VA and private treatment records. There is no indication in the record that additional evidence relevant to the issues decided herein is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. The Veteran underwent a VA examination in April 2011. After reviewing the claims file, performing a physical examination, and interviewing the Veteran, the examiner set forth a medical opinion that was supported with rationale. The examination and examination opinions are considered adequate for decisional purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board remanded the claim to have the RO obtain a pertinent medical opinion from the Under Secretary for Health. In February 2013, the RO received opinions from the Director, Post 9-11 Era Environmental Health Program (DEHP) (written for the Under Secretary), and Director of Compensation Purposes. The opinions address the requested development in the Board's January 2013 remand directive and a more than adequate. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand 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). Some discussion of the Veteran's personal hearings is also necessary. The individual presiding over a hearing must comply with the duties set forth in 38 C.F.R. § 3.103(c)(2). Bryant v. Shinseki, 23 Vet. App. 488 (2010). These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. They were met here in both instances. The issue on appeal (service connection) was identified at both of the Board hearings. Information was also elicited from the Veteran concerning the onset of his hyperthyroid symptoms, when he was initially diagnosed, as well as the manner this condition is felt to be related to active duty service, to include his exposure to ionizing radiation and service in SWA. Development ensued as a result of the Veteran's testimony. II. Analysis The Veteran seeks service connection for a thyroid disorder or Grave's Disease as a qualifying chronic disability under 38 C.F.R. § 3.317 (undiagnosed illness), or as due to exposure to radiation and/or toxic chemicals. Specifically, he contends that his thyroid disorder and/or Graves Disease were caused by in-service exposure to depleted uranium during his service in Iraq and Kuwait. He also argues that the cause of Grave's disease is unknown, and that the benefit of the doubt should be given to finding that it is essentially an undiagnosed illness. (i) General Service Connection Criteria Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110 , 1131 (West 2002). Generally, the evidence must show: (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, 1166 -67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Certain chronic diseases, such as endocrinopathies, which would include Grave's disease, are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). 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 if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a); endocrinopathies are a qualifying chronic disease. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As a result, service connection via the demonstration of continuity of symptomatology is applicable in the present case. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). If there is at least an approximate balance of positive and negative evidence regarding any issue material to the claim, the claimant shall be given the benefit of the doubt in resolving each issue. 38 U.S.C.A. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. §§ 3.102. On the other hand, if the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. Service treatment records are negative for any complaints, treatment, or diagnosis of Grave's disease or any other thyroid or endocrinopathy. The Veteran's service discharge examination is essentially negative in this respect. There is also no evidence of a diagnosis of an endocrinopathy within a year of service discharge. The initial diagnosis of Grave's disease was in 2004, which is over 10 years post-service. There is also no evidence that the Veteran experienced any symptoms of his thyroid disorder on a continuous basis since service. In other words, there is no basis for the award of service connection on a direct basis, presumptive basis under 3.309(a), or based on continuity of symptomatology. The Veteran does not argue the contrary. Rather, as highlighted in greater detail below, he maintains that his thyroid disorder, to include Grave's disease, is the result of his in-service exposure to ionizing radiation or exposure to toxic chemicals. He alternately contends that his thyroid problem should be construed as a qualifying chronic disability that has not been attributed to any known clinical diagnosis and became manifest as a result of his service in the Southwest Asia theater of operations during the Persian Gulf War. (ii) Qualifying Disability-3.317 The Veteran's service personnel records, to include his DD 214 reflect that he served in Southwest Asia from December 27, 1990 to June 28, 1991. Because the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War, service connection may also be established under 38 C.F.R. § 3.317. Under that section, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War. For disability due to undiagnosed illness and medically unexplained chronic multi symptom illness, the disability must have been manifest either during active military service in the Southwest Asia Theater of operations or to a degree of 10 percent or more not later than December 31, 2016. 38 C.F.R. § 3.317(a)(1) . For purposes of 38 C.F.R. § 3.317 , there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A 1117(d) warrants a presumption of service connection. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). Here, while the Veteran served in the Persian Gulf War, the evidence clearly establishes that the Veteran's illness has been attributed to a known clinical diagnosis. Specifically, he was diagnosed as having Grave's disease and goiter. See April 2011 VA examination report. Accordingly, service connection under 38 C.F.R. § 3.317 is not permitted as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426 (1994). (iii) Radiation/Toxic Chemical Exposure The Veteran argues that his thyroid disorder and/or Graves Disease were caused by in-service exposure to depleted uranium during his service in Iraq and Kuwait. He states that this exposure occurred from January to July 1991 while he was assigned to the 542 Transportation Company. He maintains that he hauled tanks that been blown up with white phosphorous. See Radiation Risk Activity Information Sheet, received by the RO in April 2006; VA Form 21-4138, Statement in Support of Claim, dated and signed by the Veteran in February 2009 and T. at pg. 4. Establishing service connection for a disorder as due to ionizing radiation exposure during service can be shown in three different ways. Ramey v. Brown, 9 Vet. App. 40 (1996). First, a radiation-exposed veteran may be presumptively service-connected for any of the specific diseases listed in 38 C.F.R. § 3.309(d) , which encompass a variety of different forms of cancer. A "radiation-exposed veteran" is one who participated in a radiation-risk activity which, by definition, means the onsite participation in a test, or within six months of the test, involving the atmospheric detonation of a nuclear device, occupation of Hiroshima or Nagasaki during World War II, or presence at other certain specified sites. 38 C.F.R. § 3.309(d)(3). In applying this statutory presumption, there is no requirement for documenting the level of radiation exposure. If the requirements for presumptive service connection under 38 C.F.R. § 3.309(d)(3) are not met, service connection may also be established if the evidence shows the existence of any other "radiogenic" diseases, such as any form of cancer listed under 38 C.F.R. § 3.311(b)(2) or other claimed diseases considered to be radiogenic through a showing of competent scientific or medical evidence. 38 C.F.R. § 3.311(b)(4) . When it has been determined that: (1) a veteran has been exposed to ionizing radiation; (2) the veteran subsequently develops a specified radiogenic disease; and (3) the disease first becomes manifest five years or more after exposure, the claim will be referred to the Under Secretary for Benefits for further consideration in accordance with 38 C.F.R. § 3.311(c) . When such a claim is forwarded for review, the Under Secretary for Benefits shall consider the claim with reference to 38 C.F.R. § 3.311(e) and may request an advisory medical opinion from the Under Secretary of Health. 38 C.F.R. §§ 3.311(b), (c)(1). The medical adviser must determine whether sound scientific and medical evidence supports a conclusion that it is "at least as likely as not" that the disease resulted from in-service radiation exposure or whether there is "no reasonable possibility" that the disease resulted from in-service radiation exposure. 38 C.F.R. § 3.311(c)(1) . For purposes of 38 C.F.R. § 3.311, the term "radiogenic disease" means a disease that may be induced by ionizing radiation. 38 C.F.R. § 3.311(b)(2). These include: (i) All forms of leukemia except chronic lymphatic (lymphocytic) leukemia; (ii) Thyroid cancer; (iii) Breast cancer; (iv) Lung cancer; (v) Bone cancer; (vi) Liver cancer; (vii) Skin cancer; (viii) Esophageal cancer; (ix) Stomach cancer; (x) Colon cancer; (xi) Pancreatic cancer; (xii) Kidney cancer; (xiii) Urinary bladder cancer; (xiv) Salivary gland cancer; (xv) Multiple myeloma; (xvi) Posterior subcapsular cataracts; (xvii) Non-malignant thyroid nodular disease; (xviii) Ovarian cancer; (xix) Parathyroid adenoma; (xx) Tumors of the brain and central nervous system; (xxi) Cancer of the rectum; (xxii) Lymphomas other than Hodgkin's disease; (xxiii) Prostate cancer; and (xxiv) Any other cancer. 38 C.F.R. § 3.311(b)(2) . If a claim is based on a disease other than one listed in the previous paragraph, VA shall nevertheless consider the claim under 38 C.F.R. § 3.311, provided the claimant has cited or submitted competent scientific or medical evidence that the claimed condition is a radiogenic disease. 38 C.F.R. § 3.311(b)(4). Finally, direct service connection can be established by "showing that the disease or malady was incurred during or aggravated by service," a task which "includes the difficult burden of tracing causation to a condition or event during service." Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). The Board notes at the outset that the Veteran is not a "radiation exposed veteran" for purposes of 38 C.F.R. § 3.309(d)(3), as he has not participated in one of the specifically listed radiation-risk activities, such as on-site participation in an atmospheric detonation of a nuclear device, service in Hiroshima or Nagasaki following World War II, or any other specified activity. The Veteran has also not asserted such participation. However, as indicated, thyroid cancer as well as "non-malignant thyroid nodular disease," are considered radiogenic diseases that are entitled to special development procedures under 38 C.F.R. § 3.311(c) if they first manifest five years or more after exposure. 38 C.F.R. § 3.311(b)(1) and (5)(iv) (2013). The Veteran has not been diagnosed with thyroid cancer. The DEHP indicated in a February 2013 opinion that the Veteran had "non-malignant thyroid nodular disease" (i.e., goiter) and that it had manifested five years or more after exposure. The Veteran is thereby entitled to the special development procedures under 38 C.F.R. § 3.311(b)(1). In addition, because his claim is also based on a diagnosis of Grave's Disease, a disease other than one of the diseases listed in 38 C.F.R. § 3.311(b)(2), VA shall consider the claim under the provisions of 38 C.F.R. § 3.311(b)(1) provided that he has cited or submitted competent scientific or medical evidence that the claimed condition is a radiogenic disease. There are private and VA opinions that are supportive of and against the Veteran's claim that his thyroid disability/Grave's Disease is due to in-service radiation exposure. In support of the claim that he has a radiogenic disease, the Veteran's representative pointed to a website, www.gulflink.osd.mil/forcesinhazard 00.htm, reflecting that the Veteran's unit, the 542nd Transportation Company, had been exposed to multiple chemicals from the Khamisiyah demolition. See Veteran's representative's October 2011 Informal Hearing Presentation, pg. 2. In addition, a March 2006 VA social worker entered an impression that the Veteran had a diagnosis of Grave's disease and hyperthyroidism and that he had a history of uranium exposure, as well as exposure to other toxic chemicals in Desert Storm. See March 2006 VA outpatient report. The Board finds the above-cited website and March 2006 VA social worker's clinical impression to be of minimal probative value in establishing that the Veteran has a radiogenic disease. Neither the website nor the VA social worker's impression opine that the Veteran's diagnosed Grave's Disease and goiter were caused by in-service exposure to radiation. These sources only report that the Veteran, as well as his unit, had been exposed to, or that there was a history of uranium exposure, during his service in Desert Storm. There is no evidence that the author of the above-referenced website or the VA social worker had precise knowledge of the degree of the Veteran's claimed exposure; nor did the VA social worker provide any further rationale as to her clinical impression as it related to the Veteran's development of Grave's disease/hyperthyroidism and his history of uranium exposure during Desert Storm. The website and March 2006 VA social worker's clinical impression do not indicate a review of the Veteran's service and post-service evidence records nor a competent investigation of such potential exposure as is found in the dose estimate. By contrast, a review of the Veteran's service and post-service evidence records and a competent investigation of such potential exposure was performed as part of the an April 2011 VA examiner's opinion and February 2013 opinions of the Director, Post 9-11 Era Environmental Health Program (written for the Under Secretary of Health) and Director of Compensation Purposes, respectively. These opinions, taken together, hold much greater probative value in establishing that the Veteran does not have a radiogenic disease. The VA examiner opined that the Veteran's current (then) diagnosis of Grave's disease was not a result or aggravation of events that occurred while in the service. The VA physician reasoned that Grave's disease was an autoimmune condition and would not be a result of environmental exposure due to his time in the Gulf War. The VA physician further concluded that there was an abundant epidemiological evidence for genetic susceptibility to Grave's hyperthyroidism. See April 2011 VA Thyroid and Parathyroid examination report. The DEHP opinion noted that the Veteran's inhalation of depleted uranium (DU) during his service in Southwest Asia would have most likely have been via inhalation. The DEHP next observed that the World Health Organization Fact Sheet Number 257, Depleted Uranium, estimated that the driver of a full loaded mark 1 Abrams tank could received as much has 0.3 microsieverts per hour. If a soldier drove a tank 10 hours a day for 30 days, this would give him a total maximum dose of microsieverts, or 9 milirems per month. Thus, the Veteran, who served in Iraq for roughly six (6) months, would have received approximately 54 millirem. It was noted that personnel not riding in a tank would have received even less exposure. The Veteran's dose was likely much less and was not likely above natural background radiations levels. In support of her findings, the DEHP further referenced an August 2004 position statement entitled, " Radiation Risk in Perspective, of the Health Physics Society." In that article, the Health Physics Society recommended against quantitative estimation of health risks below an individual dose of five (5) rem in one year or a lifetime dose of 10 rem above that received from natural sources. The position statement further stated that there was substantial and convincing scientific evidence for health risks following high-dose exposures. However below 5-10 rem (which includes occupational and environmental exposures), risks of health effects are either too small to be observed or were non existent. Thus, it was the DEHP's opinion that it was unlikely that the Veteran's Grave's Disease and/or non-malignant thyroid nodular disease (goiter) could be attributed to radiation exposure, specifically DU exposure, during military service. The Board emphasizes that the DEHP estimated that the Veteran's maximum estimated exposure to ionizing radiation was 54 millirem, which doesn't even equate to a single rem. In a February 2013 opinion, the Director of Compensation and Pension Services concluded that based on the DEHP's opinion (written for the Under Secretary of Health) and following its review of the evidence in its entirety, that there was no reasonable possibility that the Veteran's Grave's Disease and/or non-malignant thyroid nodular disease (goiter) was the result of exposure to ionizing radiation from DU during military service. In light of the above, the Veteran cannot be granted service connection pursuant to 38 C.F.R. § 3.311. The preponderance of the evidence is also against a finding of a nexus between the Veteran's goiter and Grave's Disease and his exposure to ionizing radiation/toxic chemicals. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). A March 2006 VA social worker provided a general impression that the Veteran' carried diagnoses of Grave's disease and hyperthyroidism, and that he had a history of uranium exposure, as well exposure to other toxic chemicals in Desert Storm. However, greater probative value is once again afforded to the April 2011 VA examiner, DEHP's and Director of C & P's opinions. The examiners provided rationale for their negative conclusions. Both opinions cited to supporting factual data and studies (e.g. World Health Organization Fact Sheet Number 257 and a position statement of the Health Physics Society regarding radiation exposure dosimetry estimates, to include soldiers who operated tanks). The opinions were also produced by clinical experts. Consideration has been given to the Veteran's personal assertion that there is a relationship between his thyroid disorder(s) and his military service, to include his claimed exposure to radiation and toxic chemicals therein. However, while lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, disabilities of the endocrine system, fall outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Grave's Disease and a goiter are not the type of conditions that are readily amenable to mere lay diagnosis or probative comment regarding their etiology, as the evidence shows that laboratory results and other specific findings are needed to properly assess and diagnose these disorders. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); and Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). That is, although the Board readily acknowledges that Veteran is competent to report symptoms such as weight loss or other symptoms that could be attributed to thyroid dysfunction, there is no indication that he is competent to link his current diagnosis of Grave's Disease and goiter to his active military service, to include exposure to DU and/or toxic chemicals therein. The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that the Veteran received any special training or acquired any medical expertise in evaluating disorders of the endocrine system. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). Accordingly, this lay evidence does not constitute competent medical evidence and lacks probative value. The Board accords great probative weight to the DEHP's and Director of C & P Service's opinion since they were based on medical research and offer clear conclusions with supporting data, and reasoned medical explanations. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); 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 preponderance of the evidence is against the claim. ORDER Service connection for a thyroid disorder or Grave's disease, to include as a qualifying chronic disability under 38 C.F.R. § 3.317 or as due to radiation exposure and exposure to toxic chemicals is denied. ____________________________________________ Michael A. Herman Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs