Citation Nr: 18116211 Decision Date: 07/05/18 Archive Date: 07/05/18 DOCKET NO. 17-01 454 DATE: July 5, 2018 ORDER The denial of service connection for a psoriasis disability by rating decision dated April 24, 1996 was not clear and unmistakable error (CUE). New and material evidence has been submitted to reopen a claim to service connection for psoriasis. Entitlement to service connection for psoriasis is granted. Entitlement to service connection for psoriatic arthritis is granted. Entitlement to service connection for fibrocystic disease status post bilateral mastectomy is granted. Entitlement to service connection for long QT syndrome (LQTS) status post heart failure is granted. Entitlement to service connection for adenomyosis status post hysterectomy is granted. Entitlement to service connection for a lumbar spine disability is granted. Entitlement to service connection for a spinal meningitis disability is granted. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. In an April 1996 rating decision, the RO denied entitlement to service connection for psoriasis; the Veteran did not appeal that decision. 2. The April 1996 rating decision that denied entitlement to service connection for psoriasis was based on the record and the law which existed at the time and did not involve undebatable error which, had it not been made, would have manifestly changed the outcome of the decision. 3. The April 1996 rating decision that denied service connection for psoriasis on the basis that the Veteran’s preexisting psoriasis was not permanently aggravated by her service is final. 4. The evidence received since the April 1996 rating decision, including a November 2015 private correspondence, is not cumulative or redundant of evidence previously of record, and raises a reasonable possibility of substantiating the claim of entitlement to service connection for psoriasis. 5. The Veteran’s psoriasis clearly and unmistakably existed prior to her active service, and there is probative medical evidence indicated that the psoriasis disability was aggravated by her active service. 6. The Veteran has psoriatic arthritis that is related to her service-connected psoriasis. 7. Resolving reasonable doubt in the Veteran’s favor, the Veteran has a fibrocystic disease status post bilateral mastectomy disability that is a result of her military service. 8. There is an approximate balance of positive and negative evidence as to whether the Veteran’s current LQTS status post heart failure is related to her military service. 9. There is an approximate balance of positive and negative evidence as to whether the Veteran’s current adenomyosis status post hysterectomy disability is related to her military service. 10. There is an approximate balance of positive and negative evidence as to whether the Veteran’s current lumbar spine disability is related to her military service. 11. There is an approximate balance of positive and negative evidence as to whether the Veteran’s current spinal meningitis disability is related to her military service. CONCLUSIONS OF LAW 1. The April 1996 rating decision that denied entitlement to service connection for psoriasis was not clearly and unmistakably erroneous. 38 U.S.C. § 5109A (2012); 38 C.F.R. §§ 3.105 (a) (2017). 2. New and material evidence has been received to reopen a claim of service connection for psoriasis. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 3. The criteria for service connection for psoriasis have been met. 38 U.S.C. §§ 1110, 1111, 1153, 5103, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.306 (2017). 4. The criteria for entitlement to service connection for a psoriatic arthritis disability are met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 5. The Veteran’s fibrocystic disease status post bilateral mastectomy disability was incurred during her military service. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(f), 3.310 (2017). 6. The Veteran’s LQTS status post heart failure disability was incurred during her military service. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(f), 3.310 (2017). 7. The Veteran’s adenomyosis status post hysterectomy disability was incurred during her military service. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(f), 3.310 (2017). 8. The Veteran’s lumbar spine disability was incurred during her military service. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(f), 3.310 (2017). 9. The Veteran’s spinal meningitis disability was incurred during her military service. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(f), 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from May 1991 to May 1995. This case comes to the Board of Veterans’ Appeals (Board) on appeal from November 2014, August 2016 and December 2016 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). Since the issuance of December 2016 statements of the case (SOCs), additional evidence has been added to the Veteran’s claims file. The representative has waived consideration of this evidence by the AOJ. The issue of entitlement to waiver of overpayment has been raised by the record in a June 2018 statement, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2017). CUE Laws and Regulations An unappealed rating decision is final based on the evidence of record (and may not be revised based on the record (unless it is shown that the decision involved CUE). 38 U.S.C. § 7105. Where CUE is found in a prior RO decision, the prior decision will be reversed or revised. For the purposes of authorizing benefits, reversal or revision of the prior decision on the grounds of CUE has the same effect as if the correct decision had been made on the date of the prior decision. 38 U.S.C. § 5109A; 38 C.F.R. § 3.105(a). There is a three-pronged test for CUE: (1) either the correct facts, as they were known at the time, were not before the adjudicator, or the statutory/regulatory provisions extant at that time were not correctly applied; (2) the error must be “undebatable” and of the sort “which, if it had not been made, would have manifestly changed the outcome at the time it was made;” (3) a determination that there was CUE must be based on the record and law that existed at the time of the adjudication in question. Damrel v. Brown, 6 Vet. App. 242, 245 (1994), citing Russell v. Principi, 3 Vet. App. 310, 313-14 (1992) (en banc). In this regard, the Board emphasizes that a CUE is a very specific and rare kind of “error.” It is the kind of error of fact or of law that, when called to the attention of later reviewers, compels the conclusion, with which reasonable minds could not differ, that the result would have been manifestly different but for the error. Fugo v. Brown, 6 Vet. App. 40, 43-44 (1993). It is not mere misinterpretation of facts. Oppenheimer v. Derwinski, 1 Vet. App. 370, 372 (1991). Determination of CUE must be based on the record and the law that existed at the time of the prior adjudication. Baldwin v. West, 13 Vet. App. 1 (1999); Caffrey v. Brown, 6 Vet. App. 377 (1994); Damrel, 6 Vet. App. 242; Fugo, 6 Vet. App. 40 (1993); Russell, 3 Vet. App. 310. A claim of CUE is a collateral attack on an otherwise final rating decision by a VA regional office. Smith v. Brown, 35 F. 3d 1516, 1527 (Fed. Cir. 1994). As such, there is a presumption of validity that attaches to a final decision, and when such a decision is collaterally attacked the presumption becomes even stronger. Fugo, 6 Vet. App. at 44. Therefore, a claimant who seeks to obtain retroactive benefits based on CUE has a much heavier burden than that placed on a claimant who seeks to establish prospective entitlement to VA benefits. Akins v. Derwinski, 1 Vet. App. 228, 231 (1991). A disagreement with how facts were evaluated is inadequate to raise the claim of CUE. Luallen v. Brown, 8 Vet. App. 92, 95 (1995). A failure in the duty to assist does not establish CUE. See Cook v. Principi, 318 F.3d 1334 (Fed. Cir. 2002). In Cook, the Federal Circuit emphasized that a purported failure in the duty to assist cannot give rise to clear and unmistakable error, nor does it result in “grave procedural error” so as to vitiate the finality of a prior, final decision. In other words, to present a valid claim of CUE, the claimant cannot simply request that the Board reweigh or reevaluate the evidence. Crippen v. Brown, 9 Vet. App. 412 (1996). Further, an alleged failure in the duty to assist by the RO may never form the basis of a valid claim of CUE, because it essentially is based upon evidence that was not of record at the time of the earlier rating decision. See Elkins v. Brown, 8 Vet. App. 391, 396 (1995). The fact that medical knowledge was not advanced to its current state may not form the basis for a valid claim of CUE, because it is premised upon facts that were not then of record. Subsequently developed evidence may not be considered in determining whether error existed in the prior decision. See Porter v. Brown, 5 Vet. App. 233, 235-36 (1993). Again, the mere misinterpretation of facts does not constitute CUE. Thompson v. Derwinski, 1 Vet. App. 251, 253 (1991). Factual Background and Analysis Essentially, the Veteran argues that there was CUE in the April 1996 rating decision that denied service connection for psoriasis. The Veteran’s representative claimed in a January 2018 correspondence that while the Veteran was denied service connection for psoriasis, the April 1996 rating decision failed to apply 38 U.S.C. § 1111 regarding the presumption of soundness as the rating decision did not meet its burden to prove a lack of aggravation of the Veteran’s psoriasis. The Veteran’s representative noted that while the Veteran had a preexisting psoriasis disability, the record contained no clear and unmistakable evidence that the disability was not aggravated by her service. Evidence considered by the RO in its April 1996 rating decision included service treatment records and a June 1995 VA examination report. The Veteran’s December 1990 enlistment examination noted that the Veteran had a history of chronic psoriasis. On VA examination in June 1995, the VA examiner diagnosed the Veteran with guttate psoriasis. The Veteran’s representative argues CUE in the May 1996 rating decision because the record contained no clear and unmistakable evidence that the Veteran’s psoriasis disability was not aggravated by service. Having carefully reviewed the record, the Board finds that a reasonable adjudicator could have found that there was clear and unmistakable evidence to rebut the presumption of soundness in view of the service treatment records and the June 1995 VA examination considered by the RO in its May 1996 adjudication. Specifically, the evidence before the RO in May 1996 included service treatment records showing a history of preexisting psoriasis. The regulations pertaining to the aggravation of a preservice disability, is the same now as it was in 1996. Notably, a preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during that active service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. Aggravation may not be conceded where the disability underwent no increase in severity during service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. On review, the Board finds that the May 1996, rating decision denying service connection for psoriasis did not involve CUE. The correct facts, as they were known at the time of the decision were before the RO, and the statutory or regulatory provisions extant at the time were correctly applied. The RO’s May 1996 rating decision explained what facts were considered in making the determination and it was the RO’s determination/judgment that the psoriasis disability preexisted her active service and was not aggravated by service. A disagreement as to how those facts were weighed or evaluated is not clear and unmistakable error. See Russell v. Principi, 3 Vet. App. 310, 313-314 (1992) (en banc). The Veteran’s representative has claimed that the record contained no clear and unmistakable evidence that the disability was not aggravated by her service. However, while the Veteran has made allegations that the law in existence at that time was misapplied, the Board finds that it appears she simply disagrees with how the facts of the case were weighed or evaluated. Notably, there was no competent medical opinion of record at the time of the May 1996 rating decision that stated that the Veteran’s preexisting psoriasis was aggravated beyond the natural progress of the disease. To the extent the June 1995 VA examiner did not render a nexus opinion, failure to obtain a medical opinion or any other duty to assist inadequacies cannot constitute CUE. See Cook v. Principi, 318 F.3d 1334 (Fed. Cir. 2002). The service treatment records also demonstrate that the psoriasis condition preexisted service. Additionally, the June 1995 VA examiner merely diagnosed the Veteran with guttate psoriasis. In short, although the Veteran admittedly was not required to show evidence that her psoriasis disability worsened or was aggravated during or by service, as noted, it was nevertheless reasonable to conclude, based on the evidence of record, that a preexisting disorder was clearly and unmistakably not aggravated by service. Consequently, this allegation of CUE goes to how the RO weighed and evaluated the facts before it in May 1996, which is in insufficient to establish CUE. Thus, the Veteran has failed to show that the facts as known at the time of the May 1996 RO decision were undebatable or that 38 C.F.R. § 3.303(b) was incorrectly applied. The Board, therefore, must find that the Veteran cannot prevail on this allegation of CUE as it goes to the weight the RO gave to the evidence of record at the time of the May 1996 decision. See Russell, 3 Vet. App. at 313-14; Damrel, 6 Vet. App. at 246. Service Connection Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). 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.” Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain diseases, to include arthritis, may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112 (2012); 38 C.F.R. §§ 3.307, 3.309 (2017). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden for certain chronic disabilities such as arthritis is through a demonstration of continuity of symptomatology. In relevant part, 38 U.S.C. § 1154(a) requires that the VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency (“a legal concept determining whether testimony may be heard and considered”) and credibility (“a factual determination going to the probative value of the evidence to be made after the evidence has been admitted”). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). Under 38 C.F.R. § 3.310(a), service connection may be granted for disability that is proximately due to or the result of a service- connected disease or injury. Such permits a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation to a nonservice- connected disability by a service- connected disability. Id. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310(b). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The provisions of 38 U.S.C. § 1111 provide that every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. This presumption attaches only where there has been an induction examination in which the later complained-of disability was not detected. Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). A pre-existing injury or disease noted at entry will be considered to have been aggravated by active service where there is an increase in disability during such service, unless clear and unmistakable evidence shows that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. The provisions of 38 C.F.R. § 3.306(b) provide that aggravation may not be conceded unless the pre-existing condition increased in severity during service. An important distinction between section 1111’s aggravation prong of the presumption of soundness and section 1153 presumption of aggravation is the burden of proof. Under section 1111, the burden is on the Government to show by clear and unmistakable evidence that there was no increase in disability in service or, that any increase was due to the natural progress of the disease. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Under section 1153, however, the Appellant bears the burden of showing that his preexisting condition worsened in service. Once the veteran establishes worsening, the burden shifts to the Secretary to show by clear and unmistakable evidence that the worsening of the condition was due to the natural progress of the disease. Horn v. Shinseki, 25 Vet. App. 231, 235 (2014). A pre-existing injury or disease will be considered to have been aggravated by active military, naval or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). 1. Entitlement to service connection for psoriasis The Veteran’s December 1990 entrance examination noted that the Veteran had a history of chronic psoriasis. A July 1994 in-service physical profile indicated that the Veteran had a diagnosis of psoriasis. The Veteran underwent a VA examination in June 1995. The examiner diagnosed the Veteran with guttate psoriasis. In a November 2015 correspondence, a private physician opined that it was as likely as not that the Veteran’s psoriasis was aggravated beyond its natural progression during her active service. The physician noted that in 1993 and 1994 the Veteran had difficulty wearing clothing and was placed on a temporary profile due to psoriasis and infection which required daily medicinal baths. The physician also noted that while the Veteran’s enlistment examination did not provide a baseline for the severity of her psoriasis, it did indicate that the Veteran’s psoriasis was “mild” and was limited to the anterior portion of her chest. The enlistment examination also noted that the psoriasis was only present in the winter and cleared up in the summer. The physician noted that the baseline then was that the psoriasis did not require any treatment and would resolve on its own during the summer months. The physician opined that this would have remained the same but the additional aggravating factors of additional clothing layers, increased sweat from the physical demands of service and increased stress during her active duty, the Veteran’s psoriasis was aggravated beyond its normal progression. The Veteran underwent a VA examination in June 2016. The examiner noted that the Veteran was diagnosed with psoriasis before service and he continued to have problems with service. The examiner indicated that without the known facts as to what the natural progression of psoriasis is, it would be merely speculative to render an opinion as to whether or not the Veteran’s service aggravated her psoriasis beyond its natural progression. The Veteran underwent a VA examination in December 2016. The examiner noted that the Veteran’s psoriasis preexisted her service and that during service she was seen for psoriasis consistent with the natural progression without evidence of permanent aggravation. The examiner noted a July 1994 in-service physical profile which noted psoriasis and infection but it was written as a temporary profile only which expired in August 1994. This was therefore an example of a simple temporary increase in the psoriasis symptoms and manifestations rather than permanent aggravation beyond natural progression. The examiner concluded that the Veteran’s psoriasis was not aggravated beyond its natural progression by an in-service event, injury or illness. Having reviewed the record, the Board finds the Veteran has current psoriasis that is shown to have been permanently aggravated beyond natural progression during service. As noted above, the Veteran’s enlistment examination indicated that the Veteran had a history of chronic psoriasis. In view of the fact that the Veteran’s pre-existing psoriasis disability was known upon entry into her period of active duty, the presumption of soundness does not apply. See 38 U.S.C. § 1111; VAOPGCPREC 3-2003. The next question is whether the disability is shown to have increased in severity in service. If so, service connection is warranted unless there is evidence that clearly and unmistakably demonstrates that the disability was not aggravated by active service beyond the natural progress of the disorder There is credible evidence that the psoriasis disability underwent an increase in severity during active service in the form of documented complaints therein and the Veteran’s recent lay assertions. Thus, there is a presumption of aggravation that can only be rebutted if it is shown by clear and unmistakable evidence that such increase was temporary or not beyond the natural progress of the disease. In this regard, the Board notes that there are conflicting opinions as to whether the Veteran’s pre-existing psoriasis disability was permanently aggravated by her service. As noted above, the November 2015 private physician opined that it was as likely as not that the Veteran’s psoriasis was aggravated beyond its natural progression during her active service. Conversely, the December 2016 VA examiner concluded that the Veteran’s psoriasis was not aggravated beyond its natural progression by an in-service event, injury or illness. It is the Board’s fundamental responsibility to evaluate the probative value of all medical and lay evidence. See Owens v. Brown, 7 Vet. App. 429 (1995); Gabrielson v. Brown, 7 Vet. App. 36 (1994); see also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (observing that the evaluation of medical evidence involves inquiry into, inter alia, the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches). While the medical evidence of record was primarily in agreement that there was aggravation of the Veteran’s psoriasis disability during her period of active service, the debatable point appears to be whether such aggravation was permanent. In this regard, the Board finds that the evidence is at the very least in relative equipoise as to whether the aggravation was permanent in nature, i.e., about evenly balanced for and against the claim. In such situations, it cannot be said that there is clear and unmistakable evidence that the disability was not aggravated. The Board notes that while the December 2016 VA examiner specifically determined that the Veteran’s pre-existing psoriasis disability was not permanently aggravated during her period of active service, the November 2015 private physician did in fact specifically address whether the Veteran’s in-service aggravation of his pre-existing psoriasis was permanent. Additionally, unlike the December 2016 VA examiner who seemingly focused solely on an in-service temporary profile, the November 2015 private physician specifically indicated that the Veteran’s psoriasis disability was permanently aggravated beyond its natural progression as the baseline of the psoriasis of not requiring any treatment and resolving on its own during the summer months would have remained the same but for the additional aggravating factors of additional clothing layers, increased sweat from the physical demands of service and increased stress during her active duty. Given the opinion and explanation of the private physician, the Board concludes that the record does not clearly and unmistakably show that the claimed disability was not aggravated beyond the natural progress of the disease. Hence, service connection for psoriasis is granted. 2. Entitlement to service connection for psoriatic arthritis After resolving all reasonable doubt in favor of the Veteran, the Board finds service connection for a psoriatic arthritis disability as secondary to her now service-connected cervical spine disability is warranted. Notably, the evidence demonstrates that the Veteran has a current psoriatic arthritis disability that was the result of her now service-connected psoriasis. Additionally, the July 2016 VA examiner specifically opined that the Veteran’s psoriatic arthritis was related to her psoriasis as psoriatic arthritis was a known complication of psoriasis. Therefore, the July 2016 positive nexus opinion of the July 2016 VA examiner provides the only competent medical opinion as to the relationship between the Veteran’s current psoriatic arthritis disability and her service-connected psoriasis disability. Additionally, a remand for a new VA examination is not necessary because the evidence of record is sufficient to grant the Veteran’s claims, and a remand would only serve to unnecessarily delay final adjudication of the claim. In sum, for the reasons and bases discussed above, the Board has resolved doubt in favor of the Veteran, and service connection for a psoriatic arthritis disability as secondary to her service-connected psoriasis disability is granted. See 38 U.S.C. § 5107(b). 3. Entitlement to service connection for fibrocystic disease status post bilateral mastectomy. In a December 2015 correspondence, a private physician noted that he had treated the Veteran while she was on active duty for fibrocystic disease. The physician noted that the Veteran would regularly visit him while she was on leave for her breast complaints. Her breasts contained multiple cysts and were consistent with fibrocystic disease. The physician learned from the Veteran that she eventually underwent a double mastectomy as a result of her ongoing breast pain. After resolving all reasonable doubt in favor of the Veteran, the Board finds service connection for a fibrocystic disease status post bilateral mastectomy disability is warranted. Initially, the Board notes that as there is a current diagnosis of fibrocystic disease status post bilateral mastectomy, the first element of service connection is satisfied. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D’Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000). The Board notes that the record contains a positive opinion from the December 2015 private physician who associates the Veteran’s fibrocystic disease to her service as he noted that he had treated the Veteran while she was on active duty for fibrocystic disease as the Veteran would regularly visit him while she was on leave for her breast complaints. Additionally, there is no competent contrary medical evidence of record that indicates that the Veteran’s fibrocystic disease was not incurred in service. Therefore, the December 2015 positive nexus opinion of the private physician provides the only competent medical opinion as to the relationship between the Veteran’s current fibrocystic disease status post bilateral mastectomy disability and her service. In sum, for the reasons and bases discussed above, the Board has resolved reasonable doubt in favor of the Veteran, and service connection for a fibrocystic disease status post bilateral mastectomy disability is granted. See 38 U.S.C. § 5107(b). 4. Entitlement to service connection for LQTS status post heart failure. In a May 2014 heart Disability Benefits Questionnaire (DBQ), a physician noted that the Veteran had LQTS. The physician noted that in 1992 the Veteran experienced severe heart palpitations and irregular heart rate after a 12-mile march. She also had persistent episodes of fatigue, dizziness and palpitations. The physician noted that the Veteran had congenital LQTS undiagnosed from her active duty. In a November 2015 correspondence, a private physician noted that a June 1992 electrogram tracing showed prolonged QT interval in sinus rhythm. Therefore, the physician found that it was reasonable to conclude that LQTS was manifest in 1992. In a December 2015 correspondence, a private physician noted that he had treated the Veteran while she was on active duty. While on leave the Veteran would present to him with complaints of recurrent lightheadedness and dizziness which was later diagnosed as LQTS. The physician noted that the diagnosis of LQTS was consistent with her history of near syncope and syncope while on active duty. The Veteran underwent a VA examination in December 2016. The examiner noted that the Veteran had been diagnosed with multiple diagnoses including LQTS and congestive heart failure. The examiner indicated that LQTS was typically an inherited genetic condition, as was the case with the Veteran, as genetic testing in December 2010 confirmed that she had LQTS that was caused by the KCNQ1 gene mutation. The examiner stated that because the LQTS was a confirmed genetic inherited condition, it therefore existed prior to military service. The examiner found that a condition that existed prior to military service could not be a result of military service and therefore was not incurred in or caused by the claimed in-service event, injury or illness including the ECG finding of prolonged QT interval and fainting and dizziness in service. The examiner also opined that the Veteran’s preexisting LQTS was not aggravated beyond its natural progression by an in-service event, injury or illness. The examiner noted that there were multiple lay statements indicating that the Veteran had lightheadedness and dizziness while in service. However, this history of possible symptoms related to LQTS triggered by physical activity was consistent with what would normally be expected for LQTS and therefore was not evidence of permanent aggravation of the LQTS. In a January 2018 correspondence, the physician who provided the December 2015 positive nexus opinion again opined that it was as likely as not that the Veteran’s LQTS was related to her military service. The physician specifically indicated that he disagreed with the findings of the December 2016 VA examiner. The physician noted that while the VA examiner correctly found that the Veteran’s LQTS was confirmed by genetic testing which showed a mutated KCNQ1 gene, the examiner incorrectly used this information to conclude that the Veteran’s LQTS was congenital and preexisted her military service. The physician noted that he could find no evidence of a diagnosis of LQTS prior to service nor did the Veteran display any symptoms that could be attributed to undiagnosed LQTS. While the Veteran did have a genetic mutation of the KCNQ1 gene, this was not equivalent to a diagnosis of LQTS and many people have mutated versions of the KCNQ1 gene and never develop LQTS or any other heart condition. The physician explained that the VA examiner’s opinion conflated the Veteran’s genetic predisposition with a confirmed diagnosis of LQTS but that this was not the case. The physician noted that some lifestyle and environmental exposures and modifications may accelerate or trigger the development of a disease such as LQTS in people with a genetic predisposition which is what happened with the Veteran. The physician indicated that simple carriership of a gene mutation was noteworthy but often failed to predict clinical outcome in that many carriers never develop clinically relevant disease while others are severely affected at a young age. Regarding the Veteran, it was clear that her LQTS first manifested during her military service as she began experiencing lightheadedness, dizziness, fainting and shortness of breath during her military service. These symptoms were observed and documented by lay statements and the Veteran’s service treatment records show that she suffered severe anaphylaxis from a scorpion bite. When combining the Veteran’s 1992 ECQ which confirmed prolonged QT interval with the Veteran’s reported symptoms, this demonstrates that the LQTS first manifested in service. The physician concluded that it was at least as likely as not that the Veteran’s LQTS was due to or incurred in her military service. After resolving all reasonable doubt in favor of the Veteran, the Board finds service connection for LQTS status post heart failure is warranted. The Veteran’s medical record shows that she has been diagnosed with LQTS. Accordingly, as there is a current diagnosis of a LQTS disability, the first element of service connection is satisfied. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D’Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000). Having reviewed the record, the Board finds there is at least an approximate balance of evidence as to whether the Veteran has a current LQTS status post heart failure disability that is related to service. The Board notes that there are conflicting opinions as to whether the Veteran has a current LQTS status post heart failure disability that is due to her service. Notably, the December 2016 VA examiner determined that the Veteran’s LQTS preexisted her military service, was not incurred in or caused by the claimed in-service event, injury or illness and was not aggravated beyond its natural progression by an in-service event, injury or illness. However, in a January 2018 correspondence, a private physician opined that it was as likely as not that the Veteran’s LQTS was related to her military service. In providing this positive nexus opinion, the January 2018 physician directly addressed the negative opinion of the December 2016 VA examiner which included the conclusion that the Veteran’s LQTS preexisted her service. Notably, the private physician indicated that while the Veteran had a genetic mutation of the KCNQ1 gene, this was not equivalent to a diagnosis of LQTS as many people have mutated versions of the KCNQ1 gene and never develop LQTS or any other heart condition. The physician noted that simple carriership of a gene mutation was noteworthy but often failed to predict clinical outcome in that many carriers never develop clinically relevant disease while others are severely affected at a young age. As a result, it was clear that the Veteran’s LQTS first manifested during her military service as she began experiencing lightheadedness, dizziness, fainting and shortness of breath during her military service and these symptoms were observed and documented by lay statements. The physician concluded that it was at least as likely as not that the Veteran’s LQTS was due to or incurred in her military service. The Board also notes that the Veteran’s December 1990 enlistment examination was negative for treatments, complaints or diagnoses of a heart disability. Therefore, when affording the Veteran the benefit of the doubt, the presumption of soundness is not rebutted and the claim becomes one for service connection on a direct basis rather than a claim based on in-service aggravation of a preexisting disability. See Wagner, supra. Accordingly, as a result of the Veteran’s noted in-service complaints and the private physician’s well detailed rationale regarding why the Veteran’s LQTS did not preexist her active duty but was rather manifested first in service, the Board finds that there is an approximate balance of positive and negative evidence regarding the question of whether the Veteran had a current LQTS disability that was caused by her service. Additionally, a remand for a new VA examination is not necessary because the evidence of record is sufficient to grant the Veteran’s claim, and a remand would only serve to unnecessarily delay final adjudication of the claim. In sum, for the reasons and bases discussed above, the Board has resolved doubt in favor of the Veteran, and service connection for a LQTS disability is granted. See 38 U.S.C. § 5107(b). 5. Entitlement to service connection for adenomyosis status post hysterectomy. A July 1992 service treatment record noted a history of recurrent urinary tract infections (UTIs). The Veteran underwent a VA examination in May 2014. The examiner opined that the Veteran’s status post total abdominal hysterectomy was not as likely incurred in or caused by her military service. However, the examiner provided a somewhat confusing rationale that adenomyosis was not a cause of or a precursor of degenerative disc disease of the lumbar spine. In a November 2015 correspondence, a private physician opined that it was at least as likely as not that the Veteran’s status post total abdominal hysterectomy was due to the ovarian cysts, ruptured ovarian cysts and/or recurrent UTIs she experienced during her service. The physician noted that while on active duty, the Veteran developed numerous ovarian cysts and her service treatment records contained multiple diagnoses of recurrent UTIs. The symptoms of recurrent UTIs are similar to large ovarian cysts which causes the cysts to go undiagnosed or misdiagnosed as UTIs. Therefore, it was likely that the multiple diagnoses of UTIs the Veteran received during military service were actually symptoms of the ovarian cysts she developed. This conclusion was supported by a 1993 treatment note which indicated that the Veteran was being treated for ruptured ovarian cysts and the service treatment records noted that her UTIs were not resolved with medication. It was further noted that ovarian cysts could cause complications requiring surgeries such as hysterectomy and bilateral salpingo-oothectomy. The physician also noted that the Veteran was frequently treated in service for abdominal pain, dysuria, pain with voiding and incontinence. She was diagnosed in-service with recurrent UTIs in service and was also diagnosed and treated for ovarian cysts and a ruptured ovarian cyst in 1993. Because her UTIs did not resolve with medication, it was more likely than not that the symptoms that the Veteran were experiencing were from her ovarian cysts. The Veteran continued to experience ovarian cysts and ruptured ovarian cysts which resulted in complications requiring total abdominal hysterectomy and bilateral saplingoophectomy. Therefore, it was at least as likely as not that the Veteran’s status post total abdominal hysterectomy and bilateral saplingoophectomy was related to her military service. The Veteran underwent a VA examination in December 2016. The examiner noted that the Veteran underwent a hysterectomy as a result of adenomyosis and that the Veteran’s service treatment records were negative for diagnosis of adenomyosis. The examiner indicated that the November 2015 positive opinion of the private physician was based on mere speculation that was refuted by objective medical records which clearly and unmistakably identified that the Veteran’s hysterectomy was due to adenomyosis. Therefore, adenomyosis status post hysterectomy was less likely than not incurred in or caused by the claimed in-service event, injury or illness including a history of ovarian cysts and UTIs in service. The examiner also noted that the Veteran’s saplingoophectomy was performed to treat abdominal pain and constipation attributed to ovarian cysts and adhesions from her hysterectomy. The examiner found that the onset of the Veteran’s symptoms treated with saplingoophectomy occurred after the Veteran’s hysterectomy and therefore was consistent with being caused by adhesions following the hysterectomy and not by ovarian cysts. Therefore, it was likely that the Veteran’s saplingoophectomy was most likely a result of an event that took place after military service, specifically the hysterectomy, and was not a result of military service. After resolving all reasonable doubt in favor of the Veteran, the Board finds service connection for status post hysterectomy is warranted. The Veteran’s medical record shows that she has been diagnosed with a status post hysterectomy disability. Accordingly, the first element of service connection is satisfied. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D’Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000). Having reviewed the record, the Board finds there is at least an approximate balance of evidence as to whether the Veteran has a current status post hysterectomy that is related to her service. The Board notes that there are conflicting opinions as to whether the Veteran’s current status post hysterectomy is related to her service. Notably, the December 2016 VA examiner opined that the Veteran’s adenomyosis status post hysterectomy and saplingoophectomy were less likely than not incurred in or caused by the claimed in-service event, injury or illness. Conversely, the November 2015 private physician opined that it was at least as likely as not that the Veteran’s status post total abdominal hysterectomy was due to the ovarian cysts, ruptured ovarian cysts and/or recurrent UTIs she experienced during her service. Notably, both the December 2016 VA examiner and the November 2015 private physician indicated that they reviewed the Veteran’s service and post-service treatment records while they both also provided a detailed history and detailed rationale for their opinions. Notably, the November 2015 provided great detail for the rationale that the Veteran’s status post total abdominal hysterectomy was due to the ovarian cysts, ruptured ovarian cysts and/or recurrent UTIs she experienced during her service. As noted above, the physician indicated that because the Veteran’s recurrent in-service UTIs did not resolve with medication, it was more likely than not that the in-service symptoms that the Veteran were experiencing were from her ovarian cysts which resulted in complications requiring total abdominal hysterectomy and bilateral saplingoophectomy. As a result, the Board finds that there is an approximate balance of positive and negative evidence regarding the question of whether the Veteran has a current status post hysterectomy disability that is related to her service. Additionally, a remand for a new VA examination is not necessary because the evidence of record is sufficient to grant the Veteran’s claim, and a remand would only serve to unnecessarily delay final adjudication of the claim. In sum, for the reasons and bases discussed above, the Board has resolved doubt in favor of the Veteran, and service connection for status post hysterectomy is granted. See 38 U.S.C. § 5107(b). 6. Entitlement to service connection for a lumbar spine disability. The Veteran underwent a VA examination in May 2014. The examiner noted a diagnosis of degenerative disc disease of the lumbar spine. The Veteran reported a gradual onset of low back pain which began while she was in the military around 1993 or 1994. The examiner noted that scoliosis of the spine was documented in x-rays in 1993 and 1994. The examiner opined that it was at least as likely as not that the Veteran’s degenerative disc disease of the lumbar spine was incurred in or caused by complaints of back pain and a medical visit to rule out inflammatory disease, as well as multiple medical visits for UTIs that occurred from 1991 to 1995. The examiner noted that based on the Veteran’s examination, her history and the claims file, there was currently sufficient evidence to suggest that the veteran’s degenerative disc disease was incurred in or caused by her complaints of back pain in service. The examiner noted that in July 1994, the Veteran presented with complaints of back pain due to the physically demanding nature of the military. The examiner found that the Veteran’s low back pain while in service was consistent with the degenerative disc disease found on the examination today. In a May 2015 correspondence, a private physician opined that it was at least as likely as not that the Veteran’s degenerative disc disease of the lumbar spine was incurred in or caused by her military service. The physician noted that x-rays in 1993 and 1994 confirmed the presence of scoliosis while the Veteran was also treated for back pain. The physician agreed with the May 2014 VA examiner that the Veteran’s lumbar spine disability while in service was consistent with her current degenerative disc disease. The physician further added that the current state of the Veteran’s lumbar spine disability was more advanced than expected of a person of her age. This was consistent with her longstanding scoliosis and back problems that manifested during her military service. The Veteran underwent a VA examination in December 2016. The examiner found that the Veteran’s service treatment records were without evidence of a chronic back condition as there was no diagnosis of degenerative disc disease and only informal, unconfirmed incidental findings of asymptomatic possible sigmoid scoliosis on a May 1994 chest x-ray. The examiner noted that although the Veteran presented with low back complaints in July 1994, after examination this complaint was assessed and was attributed to a possible kidney infection and not to the spine. Therefore, the examiner found that the Veteran’s service treatment records were unremarkable for a chronic back condition except for a possible sigmoid scoliosis that was most likely identified in error caused by incorrect positioning, the Veteran’s pneumonia and evaluation by chest x-ray not intended to assess the spine. Notably, an August 2010 x-ray demonstrated changes in L3-L4 that were consistent with aging and were without continuity to service. The August 2010 x-ray also did not show the L5-S1 degenerative disc disease which was later demonstrated in the May 2014 x-ray. The examiner found that the interval development of degenerative disc disease of the L5-S1 from August 2010 to May 2014 was clear and unmistakable evidence that the Veteran’s current degenerative disc disease of the L5-S1occured after military service, was consistent with aging and was therefore not a result of military service. The examiner concluded that the Veteran’s currently diagnosed degenerative disc disease of the L5-S1 with mild scoliosis without spinal stenosis was less likely than not incurred in or caused by the claimed in-service injury, event or illness including complaints of back pain from a kidney infection and incidental x-ray findings of scoliosis on a chest x-ray. After resolving all reasonable doubt in favor of the Veteran, the Board finds service connection for a lumbar spine disability is warranted. The Veteran’s medical record shows that she has been diagnosed with a lumbar spine disability. Accordingly, the first element of service connection is satisfied. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between her military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D’Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000). Having reviewed the record, the Board finds there is at least an approximate balance of evidence as to whether the Veteran has a current lumbar spine disability that is related to her service. The Board notes that there are conflicting opinions as to whether the Veteran’s current lumbar spine disability is related to her service. Notably, the December 2016 VA examiner opined that the Veteran’s lumbar spine disability was less likely than not incurred in or caused by the claimed in-service event, injury or illness. Conversely, the May 2014 VA examiner and May 2015 private physician opined that it was as likely as not that the Veteran’s current lumbar spine disability was related to her service. Notably, the December 2016 VA examiner, the May 2014 VA examiner and May 2015 private physician all indicated that they reviewed the Veteran’s service and post-service treatment records while they also provided a detailed history and detailed rationale for their opinions. Notably, the May 2014 VA examiner and May 2015 private physician provided great detail for the rationales that the Veteran’s current lumbar spine disability was a result of her service. As noted above, both the May 2014 VA examiner and May 2015 private physician indicated that the Veteran had in-service back complaints and that the Veteran’s current lumbar spine disability was consistent with the back problems that manifested during her military service. Additionally, the May 2015 private physician also specifically noted that the current state of the Veteran’s lumbar spine disability was more advanced than expected of a person of her age. As a result, the Board finds that there is an approximate balance of positive and negative evidence regarding the question of whether the Veteran has a current lumbar spine disability that is related to her service. Additionally, a remand for a new VA examination is not necessary because the evidence of record is sufficient to grant the Veteran’s claim, and a remand would only serve to unnecessarily delay final adjudication of the claim. In sum, for the reasons and bases discussed above, the Board has resolved doubt in favor of the Veteran, and service connection for a lumbar spine disability is granted. See 38 U.S.C. § 5107(b). 7. Entitlement to service connection for spinal meningitis. An October 1992 service treatment record noted followed up treatment for aseptic meningitis. In a November 2015 correspondence, a private physician opined that it was at least as likely as not that the Veteran’s spinal meningitis and its residuals were incurred during her active duty service. The physician noted that the Veteran’s service treatment records demonstrate that the Veteran was hospitalized for spinal meningitis in 1992 and 1994. The Veteran continued to experience residuals of intermittent neck stiffness/spasm since her initial episodes of meningitis. She experienced other residual symptoms of meningitis which continued after experiencing spinal meningitis again in 2010 and 2014. The physician noted that because the Veteran’s service treatment records showed that she had experienced meningitis during her service and her subsequent treatment records show that she was treated for chronic residuals and then continued to experience recurrent meningitis, it was as likely as not that the Veteran’s current meningitis first manifested in service. The Veteran underwent a VA examination in December 2016. The examiner opined that it was less likely than not that the Veteran’s spinal meningitis was incurred in or caused by the claimed in-service event, injury or illness. The examiner noted that a review of the service treatment records was significant for a history of aseptic meningitis in service that resolved without residuals. The examiner noted that there were no complaints or evidence of residuals of aseptic meningitis that continued for over 10 years after her military separation based on post-service medical records with only recent complaints without objective continuity to military service. Therefore, the examiner found that the Veteran had a singular episode of an acute and transitory aseptic meningitis in September 1992 that objectively resolved without residuals. The examiner also noted that the May 1994 report was misinterpreted as being assessed as viral meningitis which was in error. Instead, the assessment was merely a viral illness rather than viral meningitis. Additionally, the result of the May 1994 spinal puncture was negative which was consistent with a lack of presence of viral meningitis. Therefore, the Veteran had only a single episode of spinal meningitis in service that objectively resolved without residuals which was unrelated to and without continuity to resolved aseptic meningitis without residuals in service. The examiner concluded that it was less likely than not that the Veteran’s spinal meningitis was incurred in or caused by the claimed in service injury, event or illness. After resolving all reasonable doubt in favor of the Veteran, the Board finds service connection for spinal meningitis is warranted. The Veteran’s medical record shows that she has been diagnosed with a spinal meningitis disability. Accordingly, the first element of service connection is satisfied. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between her military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D’Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000). Having reviewed the record, the Board finds there is at least an approximate balance of evidence as to whether the Veteran has a current spinal meningitis disability that is related to her service. The Board notes that there are conflicting opinions as to whether the Veteran’s current spinal meningitis is related to her service. Notably, the December 2016 VA examiner opined that the Veteran’s spinal meningitis was less likely than not incurred in or caused by the claimed in-service event, injury or illness. Conversely, the November 2015 private physician opined that it was as likely as not that the Veteran’s current meningitis first manifested in service. Notably, both the December 2016 VA examiner and the November 2015 private physician indicated that they reviewed the Veteran’s service and post-service treatment records while they both also provided a detailed history and detailed rationale for their opinions. Notably, the November 2015 provided great detail for the rationale that the Veteran’s current meningitis first manifested in service. As noted above, the physician noted that the Veteran’s service treatment records showed that she had experienced meningitis during her service and her subsequent treatment records showed that she was treated for chronic residuals and then continued to experience recurrent meningitis. As a result, the Board finds that there is an approximate balance of positive and negative evidence regarding the question of whether the Veteran has a current spinal meningitis disability that is related to her service. Additionally, a remand for a new VA examination is not necessary because the evidence of record is sufficient to grant the Veteran’s claim, and a remand would only serve to unnecessarily delay final adjudication of the claim. In sum, for the reasons and bases discussed above, the Board has resolved doubt in favor of the Veteran, and service connection for spinal meningitis is granted. See 38 U.S.C. § 5107(b). REASONS FOR REMAND Regarding the Veteran’s claim for a TDIU, as discussed above, the Board has granted the Veteran’s claims for service connection for psoriasis, psoriatic arthritis, fibrocystic disease status post bilateral mastectomy, LQTS, adenomyosis status post hysterectomy, a lumbar spine disability and a spinal meningitis disability in this decision. The agency of original jurisdiction (AOJ) will assign a disability rating for these disabilities in the first instance. Clearly, the AOJ has not had the opportunity to consider the Veteran’s TDIU claim in light of the Board’s grants of service connection for psoriasis, psoriatic arthritis, fibrocystic disease status post bilateral mastectomy, LQTS, adenomyosis status post hysterectomy, lumbar spine and spinal meningitis disabilities. The matter is REMANDED for the following action: 1. The RO should assign disability ratings for the Veteran’s service-connected psoriasis, psoriatic arthritis, fibrocystic disease status post bilateral mastectomy, LQTS, adenomyosis status post hysterectomy, lumbar spine and spinal meningitis disabilities in the first instance. 2. Then, the RO or the AMC should readjudicate the Veteran’s claim of entitlement to TDIU. If the benefit sought on appeal is not granted to the Veteran’s satisfaction, the RO or the AMC should furnish to the Veteran and her representative an SSOC and afford them the requisite opportunity to respond. Thereafter, if   indicated, the case should be returned to the Board for further appellate action. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD James A. DeFrank, Counsel