Citation Nr: 18149954 Decision Date: 11/14/18 Archive Date: 11/14/18 DOCKET NO. 16-43 428 DATE: November 14, 2018 ORDER Service connection for a skin disorder, to include psoriasis and/or psoriatic arthritis, is denied. Service connection for a respiratory disorder, to include asbestosis and asthma, is denied. FINDINGS OF FACT 1. The evidence does not demonstrate that the Veteran’s psoriasis and/or psoriatic arthritis was incurred in service or within one year of military service, or is otherwise related to military service. 2. The evidence does not demonstrate that the Veteran’s asthma was incurred in or otherwise related to military service; the Veteran is not shown to have asbestosis during the appeal period. CONCLUSIONS OF LAW 1. The criteria for service connection for a skin disorder, to include psoriasis, are not met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for a respiratory disorder, to include asbestosis or asthma, are not met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant served on active duty in the Navy from June 1967 to March 1971. This matter comes before the Board of Veterans’ Appeals (Board) from a June 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Board previously remanded this matter in October 2017, and it had been returned to the Board at this time for further appellate review after substantially compliance with the prior remand directives. See Stegall v. West, 11 Vet. App. 268 (1998) (A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order). Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. “To establish a right to compensation for a present disability, a Veteran 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’—the so-called ‘nexus’ requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including arthritis and other organic diseases of the nervous system, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a) (3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). Psoriasis, asbestosis, and asthma are not qualifying chronic disabilities for the purposes of these provisions. Skin Disorder After review of the claims file, the Veteran is shown to have psoriatic arthritis; he therefore has a current skin disability, and the first element of service connection has been met in this case. On appeal, the Veteran reported in his July 2015 notice of disagreement that he was diagnosed with a skin disability while on active duty and that such worsened within 30 days of discharge. He self-treated with skin creams and sunlight as he did not have health insurance. He stated that 80 percent of his body was covered with open sores and he experienced psoriatic arthritis. Additionally, in a October 2017 statement, the Veteran contended that his psoriasis was present in service but misdiagnosed as cellulitis. He also surmised that his earwax problems were related to his psoriasis because he stopped experiencing ear blockages after he was diagnosed with and treated for psoriasis. See also January 2018 statement. While service treatment records indicate treatment for earwax (cerumen), a right hand infected cut which caused cellulitis, a left foot infection, and right elbow warts, the Veteran’s March 1971 separation examination was normal in all pertinent respects. His lungs, chest, skin, and lymphatic system were specifically examined and found to be normal at that time. A May 1972 clinical note from Straub Medical Research Institute states that the Veteran reported that his health was generally good. He had been a heavy smoker but recently was down to less than a pack a day. He reported past health history of losing 10 pounds due to stress, a prior bout of strep throat, and the removal of warts or moles. A chest X-ray had no significant abnormality. The Veteran was seen at Straub Clinic and Hospital in April 1977 for chest pain. He reported that he felt basically well otherwise. He endorsed a three-year history of chest pain. Dermatologic examination was unremarkable. An April 1991 clinical note states that the impression was psoriasis; it was noted that he first too methotrexate one year ago and that he began using cortisone lotion three years ago. A March 2000 clinical note states that the Veteran has a 10-year history of psoriasis and associated arthritis. An October 2002 clinical note states that the Veteran has had psoriasis for 12 to 15 years. An October 2006 clinical note states that the Veteran has had psoriasis for 20 years. A September 2008 clinical note states that the Veteran has had psoriasis since age 40. A November 2009 clinical note states that the Veteran has a 15-year history of psoriasis of the skin and psoriatic arthritis. A June 2010 clinical note states that the Veteran was diagnosed with psoriasis 20 years prior. In connection with his claim, the Veteran was afforded a VA medical examination in June 2015. The examiner diagnosed the Veteran with psoriasis, but opined that it was less likely than not that it was caused by or incurred in active service because the Veteran was not diagnosed with psoriasis while in service. Although the examiner noted service treatment records documenting that he underwent treatment for cellulitis and warts while in service, he did not explain whether psoriasis was etiologically related to either. Thus, the Board affords this opinion minimal probative weight, as most of the probative value of a medical opinion comes from its reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Another VA medical opinion was obtained in January 2018. That examiner reviewed the claims file and opined that it was less likely than not that the Veteran had a skin disability, to include psoriasis, which was incurred in or otherwise causally related to his active service. It was noted that he received treatment in 1967 for cellulitis of the right palm due to an infected cut and an infection of the left foot which was treated with soaks. In 1969, right elbow warts were treated with liquid nitrogen. Such were the only skin disorders for which the Veteran was treated in service. It was further noted that the Veteran was also treated for earwax (cerumen) on one occasion. However, the examiner stated that none of these could in any way be stretched into a diagnosis of psoriasis, as each condition had very clear-cut medical settings, which were in no way related to psoriasis or could be confused with psoriasis; psoriasis had very distinct and typical skin manifestations. The examiner noted that increased earwax may occur from many causes, the most common of which were narrow ear canals and genetic causes. Further, during the Veteran’s separation examination in March 1971, his skin was found to be normal. The examiner finally observed that dermatologic examination during a thorough April 1977 physical examination was dermatologically normal. Initially, the Board acknowledges the Veteran’s statements that he had a worsening of his psoriasis within 30 days of discharge and/or that his psoriasis is related to various treatments in service for cerumen and/or cellulitis. Although the Veteran is competent to relate symptomatology that he experienced, he is not competent to render a diagnosis or to provide a medical opinion related to etiology in this case, as he lacks the requisite medical knowledge and expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis); see also Jones v. West, 12 Vet. App. 383, 385 (1999) (where the determinative issue is one of medical causation or a diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue). Additionally, the Board reflects that the Veteran’s psoriasis and/or psoriatic arthritis is now shown in service or for many years thereafter. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim, which weighs against the claim). Accordingly, the Board must deny service connection on a presumptive basis in this case. See 38 C.F.R. §§ 3.307, 3.309. Turning to the other evidence of record regarding a nexus in this case, although the Board reflects that the Veteran stated that his skin symptomatology worsened within 30 days of military service and has been chronic and continuous since service, the Board finds those statements are not credible in light of the Veteran’s normal skin examination on separation from service, the 1977 skin examination that was unremarkable, and the wealth of other evidence that demonstrates that the Veteran began complaining and treating his psoriasis more than a decade after his discharge from service. Instead, the Board finds the January 2018 examiner’s opinion highly probative because it was based on a review of the claims file and consideration of the relevant medical history, and the opinion was accompanied by a detailed rationale. See Guerrieri v. Brown, 4 Vet. App. 467 (1993) (the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches.). The Board reflects that the January 2018 examiner’s opinion is bolstered in this case by the June 2015 examiner’s opinion. In any event, the evidence of record at this time does not refute or otherwise outweigh the probative value of the January 2018 VA examiner’s opinion in this case. Accordingly, the Board finds that the Veteran’s current skin disorder is not shown by the evidence of record to have been incurred in or within one year of discharge from service, or shown to be otherwise related to military service. The Veteran’s service connection claim must therefore be denied based on the evidence of record at this time. See 38 C.F.R. §§ 3.102, 3.303. Respiratory Disorder On appeal, the Veteran contends that he was exposed to asbestos aboard the U.S.S. Kawishiwi, where his duties included removing asbestos from bulkheads, overheads, and piping. He also cleaned black oil, JP-5, and aviation gas tanks. The Veteran reported that, during and after his service, he experienced shortness of breath and noises coming from his lungs, which was “eventually diagnosed by [VA] as asthma.” He contended that such was caused by cleaning the insides of black oil tanks 12 to 18 hours per day. The Veteran’s March 1971 separation examination was normal in all pertinent respects. His lungs, chest, skin, and lymphatic system were specifically examined and found to be normal at that time. A May 1972 clinical note from Straub Medical Research Institute states that the Veteran reported that his health was generally good. He had been a heavy smoker but recently was down to less than a pack a day. He reported past health history of losing 10 pounds due to stress, a prior bout of strep throat, and the removal of warts or moles. A chest X-ray had no significant abnormality. The Veteran was seen at Straub Clinic and Hospital in April 1977 for chest pain. He reported that he felt basically well otherwise. He endorsed a three-year history of chest pain. An April 1977 radiology report states that the chest was normal. A May 1979 clinical note from the Fronk Clinic states that the chest was normal. In connection with the claim, the Veteran was afforded a VA medical examination in June 2015. The examiner diagnosed the Veteran with asthma, but opined that it was less likely than not caused by asbestos exposure because the Veteran had not been diagnosed with asbestos exposure while on active duty. An opinion regarding the Veteran’s contended exposure to black oil and other chemicals when cleaning tanks was not offered. Thus, the Board affords this opinion minimal probative weight, as most of the probative value of a medical opinion comes from its reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Another VA medical opinion was obtained in January 2018. The claims file was reviewed. The examiner opined that it was less likely than not that the Veteran had a respiratory disorder which was incurred in or otherwise causally related to his active service. Initially, the examiner noted that the Veteran did not have asbestosis and that this was evidenced by the fact that there was a normal CT of his lungs, which is considered the diagnostic gold standard in assessing the presence of asbestosis. Further, the Veteran did not have mesothelioma or asbestos plaques on the pleura or lung tissue. The examiner explained that the only other lung disability known to be produced by asbestos was interstitial pulmonary fibrosis. However, such was easily ruled out in the instant matter due to normal CT scan and normal CO2 diffusion in pulmonary function tests (PFT). The examiner also observed that the Veteran’s lungs were normal upon separation, as evidenced by the March 1971 Report of Medical Examination and that an April 1977 physical examination, performed after the Veteran complained of recurrent chest pain, also revealed normal lungs. Further, the Veteran’s military occupational specialty (MOS) of radioman had a low probability of exposure to asbestos. Rather, the examiner noted that the Veteran was presently diagnosed with asthma, and that asthma was not caused by asbestos exposure, as the Veteran did not suffer from asbestosis, as discussed above. The examiner further explained that exposure to environmental hazards such as asbestos, black oil, JP-5, and aviation gas may produce damage to lung tissues; however, this damage occurred within the first few days and weeks following such exposure. While long-term damage could be produced, the damage would be manifested in the earlier stages of the exposures; it was “inconceivable that a person would be totally asymptomatic for several years and then develop respiratory problems after having perfectly normal lung function.” The examiner concluded that the Veteran had a normal pulmonary examination at separation from service in 1971 and several years later in 1977. Initially, with respect to the Veteran’s claim of asbestosis, the Board reflects that such is not capable of lay diagnosis in this case. Cf. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis). Furthermore, the evidence of record in this case demonstrates that the CT scan of the Veteran’s lungs does not demonstrate the presence of asbestosis and such diagnostic testing is the gold standard for determining whether such disease is present. Accordingly, as the evidence of record does not demonstrate that the Veteran has a diagnosis of asbestosis at any time during the appeal period, service connection for that claimed disease must be denied at this time based on the evidence of record. See 38 C.F.R. § 3.303; See McClain v. Nicholson, 21 Vet. App. 319 (2007) (the requirement that a current disability be present is satisfied “when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim . . . even though the disability resolves prior to the Secretary's adjudication of the claim.”); Brammer v. Derwinski, 3 Vet. App. 223 (1995) (Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability). Thus, after review of the claims file, the Veteran is shown to have asthma; he therefore has a current respiratory disability, and the first element of service connection has been met in this case. The evidence of record, however, does not demonstrate that the Veteran was shown to have asthma during military service or for many years thereafter. See Maxson, supra. Again, the Board acknowledges that the Veteran is competent to relate symptoms that he suffered, although he is not competent to render a diagnosis or otherwise opine as to the etiology of a respiratory disease in this case, as he lacks the requisite medical experience and expertise. In particular, the Board notes that whether any current respiratory disorder is related to any asbestos exposure or any other environmental exposures is inherently a complex medical question in this case. See Jandreau, supra. Consequently, insofar as the Veteran has asserted that his current asthma is related to any respiratory symptoms or environmental exposures he stated that he had during military service, such statements are not competent. Moreover, the Board finds the Veteran’s assertions that he had shortness of breath and other respiratory symptoms during and after military service to not be credible. The Board notes that the Veteran’s respiratory examination at separation from service and after discharge in 1977 were normal, without any evidence of asbestosis at any time throughout the record. The Board finds the other evidence of record to be inherently more credible and probative in this case regarding the presence of respiratory dysfunction during and at separation from service. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the Veteran). Consequently, the Board finds the January 2018 examiner’s opinion highly probative because it was based on a review of the claims file and consideration of the relevant medical history, and the opinion was accompanied by a detailed rationale. See Guerrieri, supra. The Board reflects that the January 2018 examiner’s opinion is bolstered in this case by the June 2015 examiner’s opinion. In any event, the evidence of record at this time does not refute or otherwise outweigh the probative value of the January 2018 VA examiner’s opinion in this case. Accordingly, the Board finds that the Veteran’s current skin disorder is not shown by the evidence of record to have been incurred in or within one year of discharge from service, or shown to be otherwise related to military service. The Veteran’s service connection claim must therefore be denied based on the evidence of record at this time. See 38 C.F.R. §§ 3.102, 3.303. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Behlen, Associate Counsel