Citation Nr: 18157965 Decision Date: 12/14/18 Archive Date: 12/13/18 DOCKET NO. 16-52 293 DATE: December 14, 2018 ORDER Service connection for psoriasis is denied. Service connection for functional gastrointestinal disorder is denied. FINDINGS OF FACT 1. Psoriasis was not present during the Veteran’s active service or for many years after service, is not causally related to the Veteran’s active service, and is not attributable to an undiagnosed illness. 2. A functional gastrointestinal disorder was not present during the Veteran’s active service or for many years after service, is not causally related to the Veteran’s active service or a service connected disability, and is not attributable to an undiagnosed illness. CONCLUSIONS OF LAW 1. The criteria for service connection for psoriasis have not been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.317 (2018). 2. The criteria for service connection for functional gastrointestinal disorder have not been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.310, 3.317 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1988 to February 1992 and from February 2011 to August 2011. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from May 2016 and February 2017 rating decisions of a Department of Veterans Affairs (VA) Regional Office. 1. Service connection for psoriasis The Veteran contends that his current psoriasis is related to his active duty military service, including chemical exposure through laundry chemicals or ammunitions during his Gulf War service or radiation. The Veteran is a Persian Gulf Veteran within the definition of 38 C.F.R. § 3.317 as a result of his documented deployment to the Arabian Gulf from September 1991 to January 1992. See 38 C.F.R. § 3.2 (i). As a Persian Gulf Veteran, the Veteran may be entitled to compensation if he “exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of [38 C.F.R. § 3.317 ]” which have manifested to a compensable degree either in service or no later than December 31, 2021, and such symptomatology “by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis.” 38 C.F.R. § 3.317. Signs or symptoms which may be manifestations of undiagnosed illness include, but are not limited to: fatigue, signs or symptoms involving the skin, muscle or joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system, and gastrointestinal signs or symptoms. 38 C.F.R. § 3.317 (a), (b). A qualifying chronic disability means a chronic disability resulting an undiagnosed illness; a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms (chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, or any other illness that the Secretary determines meets the criteria), or any diagnosed illness that the Secretary determines warrants a presumption of service-connection. 38 C.F.R. § 3.317 (a)(2)(i). A “medically unexplained chronic multisymptom illness” is a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317 (a)(2)(ii). “Objective indications of chronic disability” include both signs, in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317 (a)(3). Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period are considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317 (a)(4). Section 1117 only provides compensation for symptoms of a chronic disability that have not been attributed to a “known clinical diagnosis.” 38 C.F.R. § 3.317 (a)(1)(ii). In this case, the medical evidence of record does not reveal any signs or symptoms that might represent an undiagnosed illness or a diagnosed medically unexplained chronic multisymptom illness. Instead, the April 2016 VA skin examiner diagnosed the Veteran with psoriasis, which resulted in red scaly lesions to the lower legs and right elbow. As such, the Veteran’s skin condition is not an undiagnosed illness. Furthermore, this examiner found that psoriasis was a chronic multi-symptom illness with a partially explained etiology; not a medically unexplained chronic multisymptom illness. No indications of chronic disability remain that have not been associated with a diagnosed disability, service connection due to undiagnosed illness is not warranted under 38 C.F.R. § 3.317. Alternately, service connection for disabilities that are claimed as due to exposure to ionizing radiation during service can be established through two presumptive paths. One involves claims based on participation in a “radiation risk activity.” See 38 C.F.R. § 3.309 (d). Radiation risk activities are defined by regulation. In this case, the Veteran’s actual radiation exposure in service is documented. The Veteran’s service records show .003 REM gamma and x-ray exposure and .025 REM neutron exposure. Nevertheless, the Veteran is not claiming a disease for which presumptive service connection is available for veterans who participated in radiation risk activities. See id. Thus, presumptive service connection is not warranted based on application of 38 C.F.R. § 3.309 (d). The other path to establishing service connection for a disability that is claimed as due to exposure to ionizing radiation is if the disability is a “radiogenic disease,” that is, “a disease that may be induced by ionizing radiation.” 38 C.F.R. § 3.311 (b)(2). Psoriasis is not among the diseases listed as a radiogenic disease under 38 C.F.R. § 3.311 (b)(2) and so presumptive service connection is not warranted. Service connection for psoriasis may still be granted on a direct basis; however, the preponderance of the evidence is against finding that a medical nexus exists between the Veteran’s psoriasis and an in-service injury, event or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The April 2016 VA examiner opined that the Veteran’s psoriasis is not at least as likely as not related to an in-service injury, event, or disease. The rationale was that the Veteran did not develop this condition until nearly twelve years after his Gulf War service. Psoriasis is a common skin condition and although its cause is not fully known, it is thought to be related to an immune system problem. Psoriasis typically starts or worsens because of an unavoidable such as infections, injury to the skin, stress, cold weather, smoking, heavy alcohol consumptions, and certain medications. Risk factors for psoriasis include the triggers, family history, stress, Vitamin D deficiency, obesity, and smoking. This Veteran’s history included Vitamin D deficiency and obesity. While the Veteran believes his psoriasis is related to an in-service injury, event, or disease, he is not competent to provide a nexus opinion in this case. As noted above, this condition did not develop until more than a decade after his in-service exposures. This issue is also medically complex, as it requires specialized medical education and the ability to determine medical causation after a significant period of time without symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran’s claims of service connection for psoriasis, and this claim must be denied. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Service connection for functional gastrointestinal disorder The Veteran contends that he has a current functional gastrointestinal disorder related to his active duty military service, including chemical exposure through laundry chemicals or ammunitions during his Gulf War service or radiation. Again, the medical evidence of record does not show a diagnosis of a presumptive radiation-related disease under either 38 C.F.R. § 3.309 (d) or 38 C.F.R. § 3.311 (b)(2). As such, service connection is not warranted on a presumptive basis due to his in-service radiation exposure. Similarly, the medical evidence of record does not reveal any signs or symptoms that might represent an undiagnosed illness or a diagnosed medically unexplained chronic multisymptom illness. Thus, service connection due to undiagnosed illness is not warranted under 38 C.F.R. § 3.317. Instead, the November 2016 VA Intestinal Conditions examiner noted gastrointestinal symptoms of intermittent diarrhea after eating some types of food and occasional episodes of bowel disturbance with abdominal distress. This examiner found that the Veteran’s symptoms were more consistent with the more common post-cholecystectomy “dumping syndrome” than an intestinal infectious or inflammatory etiology. The Veteran underwent a cholecystectomy in December 1998. After that surgery, the Veteran reported noticing significant bowel changes that caused chronic loose stools and occasional post-prandial bowel movement urgency. Service connection has not been established for disability due to the Veteran’s cholecystectomy or any gallbladder disability. As such, the Board has also considered whether service connection is warranted for this underlying condition. See DeLisio v. Shinseki, 25 Vet. App. 45, 54 (2011) (holding that a secondary service section claim premised on disability not service connection reasonably encompasses a claim for the causal disease or disability). VA did not obtain a medical nexus opinion on the issue of service connection for cholecystectomy or gallbladder disability. VA must provide a medical examination and medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79, 81-82 (2006). Here, the Board finds no evidence beyond the Veteran’s claim suggesting that he has a current condition of cholecystectomy or gallbladder disability that is causally related to his military service or was ever present during his active service. This is insufficient to warrant the need to provide a medical examination as this would, contrary to the intent of Congress, result in medical examinations being “routinely and virtually automatically” provided to all veterans claiming service connection. See Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010); see also Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010). Moreover, the evidence does not show a relevant in-service disease or injury. Neither cholecystectomy nor the underlying gallbladder condition of cholelithiasis are a presumptive radiation-related disease under either 38 C.F.R. § 3.309 (d) or 38 C.F.R. § 3.311 (b)(2). Likewise, neither is an undiagnosed or medically unexplained chronic multisymptom illness under 38 C.F.R. § 3.317. Instead, the record shows no documented gallbladder complaints for many years after service. At the time of his December 1998 surgery the Veteran reported an eight-year history of right upper quadrant pain exacerbated by fatty food intake, which suggests an in-service onset of this pain. Nevertheless, the contemporaneous service treatment records fail to reflect any abdominal complaints. Furthermore, after service the Veteran specifically denied any abdominal complaints, including gallbladder trouble or gallstones; frequent indigestions; and stomach, liver, or intestinal problems, in his Reserves Reports of Medical History in September 1992 and March 1993. No associated abnormality was note in any of the accompanying exams. Thus, the Board does not find this passing reference to an onset of pain in 1990 to be credible. As such, an opinion is not necessary and service connection for the underlying gallbladder condition is not established. Both the medical evidence and the Veteran’s lay assertions link his current gastrointestinal symptoms to his post-service cholecystectomy. The evidence of record does not establish a causal link between the Veteran’s service and his gallbladder condition upon which service connection can be granted. (Continued on the next page)   For the reasons stated above, the Board finds that the preponderance of evidence is against the Veteran’s claim of entitlement to service connection for functional gastrointestinal disorder and his appeal must be denied. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). JAMES G. REINHART Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Houbeck, Counsel