Citation Nr: 18158040 Decision Date: 12/14/18 Archive Date: 12/14/18 DOCKET NO. 15-32 031 DATE: December 14, 2018 ORDER Entitlement to service connection for a gastrointestinal disorder to include gastroesophageal reflux disease, duodenal ulcer, gastritis and peptic ulcer disease is denied. Entitlement to service connection for viral hepatitis is denied. Entitlement to service connection for a transient ischemic attack, also claimed as stroke is denied. Entitlement to a compensable evaluation for prurigo nodularis is denied. FINDINGS OF FACT 1. A chronic gastrointestinal disorder, to include gastroesophageal reflux disease, a duodenal ulcer, gastritis and peptic ulcer disease, was not demonstrated while on active duty; a peptic (duodenal) ulcer was not compensably disabling within a year of separation from active duty, and the preponderance of the competent, probative evidence is against finding a relationship between a chronic gastrointestinal disorder and the Veteran’s active duty service. 2. Viral hepatitis was not demonstrated while on active duty, and the preponderance of the competent, probative evidence is against finding a relationship between such a disorder and the Veteran’s active duty service. 3. A transient ischemic attack, also claimed as stroke, was not demonstrated while on active duty, a brain hemorrhage was not compensably disabling within a year of separation from active duty, and the preponderance of the competent, probative evidence is against finding a relationship between such a disorder and the Veteran’s active duty service. 4. Prurigo nodularis is not demonstrated by involvement with at least 5 percent of the entire body, or at least 5 percent of all exposed areas, or; by a need for intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period. . CONCLUSIONS OF LAW 1. A gastrointestinal disorder to include gastroesophageal reflux disease, claimed as duodenal ulcer, gastritis and peptic ulcer disease was not incurred in or aggravated by service; and a peptic (duodenal) ulcer may not be presumed to have been so incurred. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 2. Viral hepatitis was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.304. 3. Transient ischemic attack, also claimed as stroke, was not incurred in or aggravated by service, and a brain hemorrhage may not be presumed to have been so incurred. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for a compensable rating for prurigo nodularis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.118, Diagnostic Code 7806.   REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1968 to December 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) that denied entitlement to service connection for gastroesophageal reflux disease, viral hepatitis and transient ischemic attack, as well as a compensable evaluation for prurigo nodularis. The appeal was remanded in March 2015. The Board finds that, relative to the claims herein decided, there was substantial compliance with the remand directives. See D’Aries v. Peake, 22 Vet. App. 97, 105-106 (2008). The Veteran testified at a Board hearing before the undersigned in June 2016. A copy of that transcript is of record. The appeal was subsequently certified to the Board by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. Service Connection Generally, service connection may be established for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). In order to establish service connection, the following must be shown: (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, 1167 (Fed. Cir. 2004). Under 38 C.F.R. § 3.303(b), service connection may be established by demonstrating continuity of symptomatology. Continuity 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. The provisions of 38 C.F.R. § 3.303(b) only apply to diseases recognized by VA as “chronic.” See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.309(a). Chronic diseases that become manifest to a degree of 10 percent within one year of termination of active duty may be presumed to have been incurred in service. The list of chronic diseases includes peptic (duodenal) ulcers, and brain hemorrhage. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Gastrointestinal disorder to include gastroesophageal reflux disease, duodenal ulcer, gastritis and peptic ulcer disease The Veteran contends that a gastrointestinal disorder is related to his active service. A review of the service treatment records reveals that at induction and separation physical examinations the Veteran reported no indigestion, stomach or intestinal problems. At his Board hearing the Veteran reported that he did not seek treatment for his stomach problems until after he left active service and sought care in Port Arthur, Texas, many years after separation from service. Treatment records in the claims file include the April 1994 results of an upper gastro-endoscopy which revealed a duodenal bulb ulcer. In March 2010 the Veteran was prescribed proton pump inhibitors to relieve discomfort associated with gastroesophageal reflux disease. The Veteran sought treatment in January 2012 for stomach problems which were diagnosed as peptic ulcer disease. In November 2013 the Veteran reported similar symptoms which were characterized as dyspepsia. The Veteran clearly has a current disability relating to his digestive system. The evidence of record, however, preponderates against finding that the appellant had a chronic gastrointestinal disorder inservice, to include gastroesophageal reflux disease, gastritis or peptic ulcer disease. Further, there is no competent evidence that any currently diagnosed gastrointestinal disorder had its onset during service or is related to service in any way. While peptic (duodenal) disease may be presumptively service connected if shown to a compensable degree within one year of separation from active duty, there is no competent evidence that peptic ulcer disease was diagnosed until 1994, i.e., more than two decades after the appellant’s separation from active duty. Hence, the evidence preponderates against granting presumptive service connection. Given the absence of a chronic gastrointestinal disorder inservice, the absence of a compensably disabling peptic (duodenal) ulcer within a year of separation from active duty, and the absence of any competent evidence linking a current gastrointestinal disorder to service, the Board must find that the evidence preponderates against entitlement to service connection. As such the claim is denied. In reaching this decision the Board considered the appellant’s arguments in favor of service connection, however, as a lay person who is not trained in the field of medicine, the claimant is not competent to offer an opinion addressing the etiology of any diagnosed gastrointestinal disorder. Finally, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant’s claim, the doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Viral hepatitis The Veteran contends that he contracted hepatitis while on active duty, and that service connection is therefore warranted A review of the service treatment records reveals that while serving in Vietnam, the Veteran was hospitalized for five days, to investigate a three-day history of anorexia and dark urine. The diagnosis upon admission was “rule out hepatitis.” Shortly thereafter in April 1969, following testing and examination, to include liver function tests, the condition was diagnosed to be a viral infection and not hepatitis. In a VA examination for a different disability, in June 2001, the Veteran reported that he was “hepatitis negative.” In September 2014 the Veteran was afforded a VA examination to evaluate any medical basis for his hepatitis claim. The examiner reviewed the claim file and conducted an in-person examination of the patient. The examiner reported that the Veteran did not present with any conditions, signs, symptoms or complications associated with hepatitis. She also reported that the Veteran did not have a current diagnosis of any liver condition. It was also the opinion of the examiner that whatever condition resulted in the five-day hospitalization while the Veteran served in Vietnam, that condition was acute and was not related to any current claimed condition described by the Veteran. The Veteran was again examined for VA disability purposes in January 2015. The examiner reviewed the Veteran’s history dating back to his Vietnam hospitalization and noted addition of the appellant’s recent liver function test in May 2014, which was normal. After consideration of all of the evidence, it was the opinion of the examiner that the Veteran did not have hepatitis while in service and currently had no evidence of hepatitis or hepatitis C. Upon consideration of the foregoing, there is no competent post-service evidence demonstrating that the Veteran currently has a diagnosed disorder attributable to the hepatitis. Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. 38 U.S.C. § 1110. In the absence of proof of a present disability, there can be no valid claim. The Board’s review of the record in this case shows no competent proof of present disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As a current disability is the cornerstone of a claim for VA disability compensation, the subject claim must be denied. See Degmetich v. Brown, 104 F. 3d 1328 (1997). As the preponderance of the evidence is against the claim for service connection, the benefit-of-the-doubt rule is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Transient ischemic attack claimed as stroke The Veteran contends that his transient ischemic attack, also claimed as stroke is related to his active military service. A review of service treatment records reveals that there was no complaint, treatment or diagnosis of those conditions in-service. Examinations at entry to and separation from active duty are silent for any transient ischemic attack or related disorder. Further, there is no evidence that the appellant suffered a compensably disabling brain hemorrhage within a year of his separation from active duty. Post-separation treatment records show a singular reference to a transient ischemic attack in a March 2015 cardiology report that lists transient ischemic attack as a medical problem. The Veteran’s claim file contains no medical evidence of any formal diagnosis of a transient ischemic attack and no other reference to the condition that would relate it to any other disability. Direct service connection necessitates that the evidence show that a transient ischemic attack is related to the claimant’s active service. The evidence of record, however, preponderates against such a finding. The Veteran’s service treatment records do not contain any reports of the claimant having any conditions, symptoms, or treatment related to either transient ischemic attack, or stroke. The first report of such symptoms contained in the evidence of record was in March 2015, relating to his angiogram. That documentation dates from over 43 years after the Veteran separated from active duty. The passage of many years between discharge from active service and the documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson v. Gober, 230 F. 3d 1330 (Fed. Cir. 2000). Furthermore, the March 2015 cardiologist reference to the condition did not link a transient ischemic attack to his active-duty service in any way. None of the medical evidence anywhere in the record links a transient ischemic attack to his active service. As such, service-connection for transient ischemic attack on a direct basis is not warranted. At his hearing the Veteran testified that this disorder developed due to arteriosclerosis. The Veteran is currently service connected for coronary artery disease claimed as arteriosclerosis, and hypertension, along with other disabilities relating to peripheral neuropathy and peripheral vascular diseases. Significantly, however, there is no competent evidence showing that a transient ischemic attack is either caused or permanently aggravated by any service connected disorder. In this regard, the Board considered the Veteran’s lay statements, to include his June 2016 hearing testimony. Although the Board recognizes that the Veteran is competent to describe his observable symptoms that might support a claim for transient ischemic attack, he is not competent to opine as to the etiology of that condition, as he has not does not possess the requisite training or credentials needed to render a competent opinion as to medical diagnosis or causation. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As such, the Veteran’s lay opinion that his transient ischemic attack is related to his active service or his service-connected arteriosclerosis or hypertension is not constitute competent medical evidence and it lacks probative value. In sum, there is no competent and credible evidence that the Veteran’s transient ischemic attack, claimed as stroke, is related to service, that a brain hemorrhage was compensably disabling within a year of separation from active duty, or is secondary to any service connected disorder. Accordingly, as the preponderance of the evidence is against the claim for service connection, the benefit-of-the-doubt rule is not for application, and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990).   Increased Rating Prurigo nodularis Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. A veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Veteran contends that the current assigned rating for prurigo nodularis does not accurately reflect the severity of his skin condition. Prurigo nodularis has been rated as noncompensable since April 5, 2001 by analogy to under 38 C.F.R. § 4.118, Diagnostic Code 7803. At this time the provisions of 38 C.F.R. § 4.118 do not include that Diagnostic Code. Considering the nature and presentation of the disorder the Board finds that Diagnostic Code 7806, regarding dermatitis or eczema is most appropriate. When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. Under Diagnostic Code 7806, a 10 percent disability rating is warranted for dermatitis or eczema affecting at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas, or; requiring intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period. A non-compensable service connection rating is warranted where involvement is less than 5 percent of the entire body or exposed areas affected, and; no more than topical therapy required during the last 12-month period. 38 C.F.R. § 4.118. VA treatment records document treatment for the Veteran’s various dermatologic conditions to include folliculitis, cutaneous porphyrias, and prurigo nodularis. The Veteran has reported skin conditions affecting his extremities to include the backs of his hands, his trunk, and right flank area. He does not report, nor does the record suggest any limitation or impairment of function caused by any skin condition for any period on appeal. For a VA examination in June 2001, the Veteran reported a history of blistering of his hands related to exposure to sunlight, and earlier dermatologic treatment for porphyria cutanea tarda. Treatment regimens included cryogenic burning, topical steroids and oral antihistamines. The clinical diagnosis was folliculitis and prurigo. In conjunction with this claim, the Veteran received a VA examination for his skin disorder in September 2014. The examination results indicated no systemic or topical medications were being used at the time of the examination or for the preceding 12 months. The examiner reported no visible skin conditions to include rashes, and no benign or malignant neoplasms or metastases. The examiner also reported that no skin condition caused any scarring or disfigurement of the head, face or neck. The examiner concluded that there was no evidence of prurigo nodularis and that the condition had resolved. She also reported a review of the record indicated no documentation of the condition for the prior five years. Based upon the above, the Board finds that the preponderance of the evidence weighs against the Veteran’s claim of entitlement to a compensable initial disability rating for prurigo nodularis. Additionally, as directed by Diagnostic Codes 7806, the Board has also considered whether an increased disability rating is warranted for any period on appeal under Diagnostic Codes 7800-05 regarding disfigurement of the head, face, or neck (Diagnostic Codes 7800) or scars (Diagnostic Codes 7801-05); however, the evidence of record, including as discussed above, documents that the manifestations of the Veteran’s service connected prurigo nodularis most closely approximate the manifestations presented by dermatitis or eczema. 38 C.F.R. § 4.118. Moreover, the evidence of record does not document that residual scars from prurigo nodularis for any period on appeal. Id. In order to warrant an initial compensable disability rating under Diagnostic Codes 7806, the Veteran’s prurigo nodularis would need to affect at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas, or; require intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Codes 7806. The evidence of record, discussed above, does not document that the Veteran’s skin condition was severe enough to warrant an initial compensable disability rating for any period on appeal. The September 2014 VA examiner documented that there was no presentation of prurigo nodularis at all; moreover, while the appellant reported treatment in the past including cryogenic burning, topical steroids and oral antihistamines, the examiner found no use of medication for prurigo nodularis within the five years prior to the examination, which includes the period on appeal. As such, entitlement to a compensable disability rating is not warranted for his prurigo nodularis under Diagnostic Codes 7806. Id. As the preponderance of the evidence is against the claim for service connection, the benefit-of-the-doubt rule is not for application. Gilbert. Accordingly, the claim must be denied. DEREK R. BROWN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Allen M. Kerpan, Associate Counsel