Citation Nr: 1753529 Decision Date: 11/21/17 Archive Date: 12/01/17 DOCKET NO. 13-00 187 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for elevated liver enzymes (also claimed as idiopathic liver disease). 3. Entitlement to a compensable rating for hypertension. 4. Entitlement to a rating in excess of 30 percent for pseudofolliculitis barbae with facial scars. ATTORNEY FOR THE BOARD J. Wozniak, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1985 to February 2005. This matter came before the Board of Veterans' Appeals (Board) on appeal from April 2010 and June 2010 decisions of the Winston-Salem, North Carolina, Regional Office (RO). In July 2015, the Board remanded the appeal to the RO for additional development. Pursuant to VA's duties to notify and assist the Veteran, VA advised the claimant how to substantiate an application for benefits, obtained all relevant and available evidence and conducted any appropriate medical inquiry. The appeal is ready for appellate review. On his December 2012 and February 2013 VA Form 9s, the Veteran requested a local Board hearing. However, in an August 2014 the Veteran indicated he no longer wanted a hearing. Therefore, the Board considers the hearing request cancelled, and will proceed to adjudicate the case based on the evidence of record. See 38 C.F.R. § 20.704(e) (2017). FINDINGS OF FACT 1. An acquired psychiatric disorder, to include PTSD did not originate during active service. 2. There is no current diagnosis for elevated liver enzymes (also claimed as idiopathic liver disease). 3. During the period on appeal, the Veteran's hypertension has been shown to be manifested by no more than blood pressure readings of 150 systolic and 95 diastolic. 4. During the period on appeal, the Veteran's pseudofolliculitis barbae with facial scars has been shown to be manifested by no more than avoiding a close shave, scars totaling five or more inches (13 or more cm) in length, scars at least one-quarter inch (0.6 cm) wide at the widest part, skin hyper-pigmented in an area exceeding six square inches (39 cm squared), and no tender or painful scars. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder, to include PTSD have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 2. The criteria for service connection for elevated liver enzymes (also claimed as idiopathic liver disease) have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 3. The criteria for a compensable rating for hypertension have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.104, Diagnostic Code 7101 (2017). 4. The criteria for a rating in excess of 30 percent for pseudofolliculitis barbae have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.14, 4.85, 4.118, Diagnostic Code 7800 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection Service connection may be granted for current disability arising from disease or injury incurred or aggravated by active service. 38 U.S.C.A. § 1110. 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). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A. Acquired Psychiatric Disorder Service connection for PTSD requires medical evidence diagnosing the condition; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. If a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304(f). For injuries alleged to have been incurred in combat, 38 U.S.C.A. § 1154(b) provides a relaxed evidentiary standard of proof to grant service connection as to the in-service event. Collette v. Brown, 82 F.3d 389 (1996). Under the statute, in the case of any veteran who has engaged in combat with the enemy in active service during a period of war, satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, condition or hardships of such service, even though there is no official record of such incurrence or aggravation. Every reasonable doubt shall be resolved in favor of the Veteran. 38 U.S.C.A. § 1154(b) (West 2002); 38 C.F.R. § 3.304(d) (2010). The Veteran has been diagnosed with PTSD in a November 2010 hospital discharge summary and a May 2016 VA examination. The Veteran has made numerous statements regarding combat experiences. In an October 2009 VA treatment note the Veteran reported being involved in combat in Somalia, Iraq, and Afghanistan. In a July 2010 VA treatment record the Veteran reported that he had to clean-up the body parts of two civilians killed in Somalia. The Veteran also reported involvement in other missions but did not provide specific dates or events. In a November 2010 VA treatment note the Veteran indicated that he continually sees the faces of those who died in Somalia. In June 2010 the Veteran was issued a formal finding indicating the Veteran's records did not corroborate his claimed in-service stressors. In May 2016, the Veteran was afforded a VA examination. The examiner indicated a diagnosis for PTSD based on the Veteran's own reports of combat activity and witnessing the deaths of other soldiers and CIA agents. In November 2016, the Veteran was afforded a VA medical opinion. Based on the stressors reported by the Veteran, the examiner opined that his current PTSD symptoms were caused by his combat experiences. Hoiwever, in July 2017, the Veteran was issued another formal finding indicating the Veteran's records did not corroborate his claimed in-service stressors. The Veteran's personnel file is absent of any participation in a combat operation and contains no combat awards or citations and the Veteran has not provided VA Form 21-0871 with details of his claimed in-service stressors. The occurrence of an injury alleged to have happened in combat may be shown by lay evidence, if consistent with the circumstances, conditions, or hardships of combat, even if there is no official record of the incident. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). However, there is no probative evidence that the Veteran engaged in combat with the enemy and the combat presumption does not apply here. The May 2016 examiner noted a diagnosis for PTSD based on stressors reported by the Veteran. However, the Veteran's claims regarding in-service stressors while serving with special forces in Somalia, Iraq, and Afghanistan have not been supported by credible evidence. The Board has considered the Veteran's statements regarding in-service stressors but there is no evidence supporting service in special forces in Somalia or elsewhere and the Veteran's DD-214 indicates an occupational specialty of barber. Since there is no credible supporting evidence of an in-service stressor, service connection for an acquired psychiatric disorder, to include PTSD must be denied. B. Elevated Liver Enzymes A March 2000 service treatment record (STR) indicates the Veteran has a history of elevated liver enzymes that were possibly alcohol related. The Veteran reported his elevated liver enzymes have normalized. In April 2005, the Veteran was afforded a VA examination. The Veteran reported being told he had liver problems with enlargement of his liver and elevated ALT and AST blood levels. An ultrasound indicated the Veteran's liver was not enlarged. A September 2010 medical treatment note indicates the Veteran has an enlarged liver but was otherwise normal. In May 2016, the Veteran was afforded a VA examination. The Veteran's medical history indicated elevated liver enzymes during military service but normal liver function. The examiner reported no liver injury, cirrhosis, hepatitis C, or signs of infectious liver disease. The examiner noted abnormal liver function tests from over 18 years ago but no recent abnormal liver function results. The examiner opined that this is typical of alcohol's affect on liver function testing and indicated the Veteran has never experienced symptoms as a result of the previous abnormal liver test results. While non-medically trained veterans are competent to testify as to matters of diagnosis and etiology subject to lay observation, the question of whether a Veteran has liver disability is not a condition the Veteran is capable of diagnosing due to the medical complexity involved. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007); Layno v. Brown, 6 Vet. App. 465, 469 (1994). The preponderance of the evidence reflects that the Veteran does not have a diagnosis of a liver disability. Specifically, the examiner who conducted the May 2016 examination concluded that the Veteran has not had abnormal liver function results for over 18 years. Therefore, service connection is not warranted and the claim is denied. II. Increased Rating Claims Disability evaluations are determined by comparing the Veteran's current symptomatology with the criteria set forth in the Schedule For Rating Disabilities. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2017). Where there is a question as to which of two disability evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of, or overlapping with, the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). A. Hypertension Diagnostic Code 7101 pertains to hypertensive vascular disease (hypertension and isolated systolic hypertension). Under that code, a 10 percent rating is assigned for diastolic pressure predominantly 100mm or more, or systolic pressure predominantly 160mm or more, or where an individual with a history of diastolic pressure predominantly 100mm or more requires continuous medication for control. 38 C.F.R. § 4.104, Diagnostic Code 7101 (2017). In March 2010, the Veteran was afforded a VA examination. The Veteran reported running five miles twice a week and two miles three times a week without difficulty. The Veteran's blood pressure was measured at 138/80, 128/82, and 139/86. The examiner noted a history of hypertension with no effect on the Veteran's occupation. In a December 2010 VA treatment note the Veteran reported his blood pressure readings at home to be in the 140/90-97 range. The Veteran also indicated he was diagnosed with hypertension in 1998 but had been off medication for the preceding five years due to normal blood pressure readings at home. In May 2016, the Veteran was afforded a VA examination. The examiner noted a diagnosis of hypertension dating back to the Veteran's military service. The examiner noted the Veteran's blood pressure is controlled with systolic readings of 140-150 and diastolic readings of 90-95. During the period on appeal, the Veteran's hypertension has been shown to be manifested by no more than blood pressure readings of 150 systolic and 95 diastolic. A higher evaluation is not warranted unless there is systolic pressure of predominately 160 or more, diastolic pressure of predominately 100 or more, or a history of diastolic pressure predominantly 100 or more and there is a requirement for continuous medication for control. Therefore the claim for a compensable rating for hypertension must be denied. B. Pseudofolliculitis Barbae Diagnostic Code 7800 provides that burn scar(s) with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement, warrants a 30 percent disability evaluation. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2017). Burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement, warrants a 50 percent disability evaluation. Id. Note (1) to Diagnostic 7800 provides that the eight characteristics of disfigurement, for purposes of rating under 38 C.F.R. § 4.118, are: a scar five or more inches (13 or more cm.(centimeters)) in length; a scar at least one-quarter inch (0.6 cm.) wide at widest part; a scar in which the surface contour is elevated or depressed on palpation; a scar that is adherent to underlying tissue; the skin is shown to be hypo- or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); skin texture is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); there is underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); or the skin is indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Id. In March 2010, the Veteran was afforded a VA examination. The Veteran reported a history of various skin disorders including pseudofolliculitis barbae and treatment using topical creams that are not immunosuppressive or corticosteroids. The examiner noted the Veteran avoids a close shave and continues to have recurrent tender bumps along the beard area. The examiner noted pinpoint lesions and hyper-pigmented scaring under the chin and along the neck. In May 2016, the Veteran was afforded a VA examination. The Veteran reported avoiding a close shave and experiencing recurrent tender bumps along the beard area. The examiner noted the scars of the head, face, and neck are not painful or unstable and total 72 square centimeters. During the period on appeal, the Veteran's pseudofolliculitis barbae with facial scars has been shown to be manifested by no more than avoiding a close shave, scars totaling five or more inches (13 or more cm) in length, scars at least one-quarter inch (0.6 cm) wide at the widest part, skin hyper-pigmented in an area exceeding six square inches (39 cm squared), and no tender or painful scars. An evaluation of 50 percent is not warranted unless there is visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; four or five characteristics of disfigurement). (CONTINUED ON NEXT PAGE) ORDER Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) is denied. Service connection for elevated liver enzymes (also claimed as idiopathic liver disease) is denied. An initial compensable rating for hypertension, is denied. A rating in excess of 30 percent for for pseudofolliculitis barbae with facial scars, is denied. ____________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs