Citation Nr: 20003536 Decision Date: 01/16/20 Archive Date: 01/15/20 DOCKET NO. 17-61 861 DATE: January 16, 2020 ORDER Service connection for scleroderma is denied. Service connection for nonalcoholic fatty liver disease is denied. FINDINGS OF FACT 1. The weight of the evidence does not show that it is at least as likely as not that the Veteran’s scleroderma is etiologically related to his service. 2. The weight of the evidence does not show that it is at least as likely as not that the Veteran’s fatty liver disease is etiologically related to his scleroderma. CONCLUSIONS OF LAW 1. The criteria for service connection for scleroderma have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for nonalcoholic fatty liver disease have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran’s surviving spouse has been properly substituted as the Appellant in this appeal which was pending at the time of the Veteran’s death on July 21, 2019. The Veteran honorably served on active duty in the United States Marine Corps from February 1959 to February 1963, to include his service at Camp Lejeune, North Carolina, for more than a year between May 1959 and March 1961. In a March 2017 rating decision, the Regional Office (RO) denied his October 2014 claim for service connection for scleroderma and nonalcoholic fatty liver disease. The Veteran disagreed with the RO’s decision and appealed to the Board of the Veterans’ Appeals (Board). In seeking service connection, the Veteran was of a belief shared by the Appellant that he had incurred his scleroderma (diagnosed in March 2011 approximately fifty years after his separation from service in 1963) due to his presumptive exposure to toxins in the contaminated ground water supply at Camp Lejeune where he was stationed during his service, and that the scleroderma then caused his nonalcoholic fatty liver disease (as shown by CT imagining in March 2011). Service connection shall be granted for a disability incurred in or due to service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires the competent evidence to show the existence of the claimed disability, a relevant traumatic event in service, and a causal link between the two. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). In March 2018, upon reviewing the Veteran’s contentions, applicable law, and all evidence of record, the Board had found that the medical evidence of record was insufficient to decide the Veteran’s claim and remanded the claim for a medical expert opinion. In reaching its conclusion, the Board noted that VA had confirmed the clinical diagnoses of the Veteran’s claimed disabilities and then conceded his presumptive exposure to toxins during his service at Camp Lejeune. The Board then considered an unestablished but required causal link, so called nexus, between the Veteran’s presumptive exposure to toxins and his confirmed scleroderma, as well as between his scleroderma and his nonalcoholic fatty liver disease. Of note, the requisite nexus generally must be established by the medical evidence, unless a nexus may be presumed by operation of law or shown by the lay evidence in very limited circumstances which, as discussed below, have not been raised by the evidence of record in this case. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board initially considered that the Veteran’s service treatment records between 1959 and 1963 do not reflect any associated complaints, treatment, or diagnoses that may be associated with his scleroderma and nonalcoholic fatty liver disease first diagnosed in March 2011. The record is devoid of any contrary evidence. In light of the diagnoses many years after service, without any evidence showing or suggesting that the Veteran’s scleroderma and liver disease manifested during service or within one year of discharge, or have been incurred due to any existing service-connected disability, or have been determined to presumptively relate to any event in service, to include exposures to certain environmental hazards such as Agent Orange or toxins in the ground water supply at Camp Lejeune, the Board then turned to the medical evidence of record. See 38 C.F.R. §§ 3.303(a)-(b), 3.307(a)(3), (a)(7), 3.309(f), 3.310. Of particular note in this case were the two medical nexus opinions, namely, a VA examiner’s opinion (received in February 2016) and a private opinion of Dr. W.Z. (received in June 2017), both suggesting a possible nexus between toxic exposure and scleroderma. Neither medical opinion, however, explicitly linked the Veteran’s scleroderma to his presumptive exposure to toxins during service at Camp Lejeune. Likewise, while the VA examiner’s opinion suggested that the Veteran’s liver disease may be etiologically related to his scleroderma, neither opinion linked these two diseases. Accordingly, finding that the medical evidence of record was insufficient to decide the claim, the Board remanded the claim for a supplemental medical expert opinion which VA obtained in February 2019. In sum, the expert medical examiner rendered a negative nexus opinion that is largely based on the insufficiency of the currently available clinical evidence to causally link the Veteran’s scleroderma and liver disease to his presumptive exposure to toxins, or to link his liver disease to scleroderma, both of which were attenuated from the Veteran’s military service by about fifty years. In the intervening years, the Veteran exhibited multiple known high-risk factors for developing these diseases. The examiner concluded that the identified risk factors, etiologically unrelated to the Veteran’s service, are the most likely causes for the Veteran’s claimed disabilities. More specifically, the February 2019 report reflects that the examiner evaluated the Veteran in-person, reviewed the relevant medical research, and then reviewed his complete medical history, to include his service treatment records, his VA and private treatment records along with the past medical examinations and opinions. Based on the comprehensive data, the examiner ultimately concluded that the Veteran’s scleroderma was less likely than not to have been caused by his exposure to toxins and his liver disease was less likely than not to have been either caused or aggravated by scleroderma. The examiner explained at some length the scientific intricacies of the available medical research on possible causal links between scleroderma and exposure to toxins, discussed pathologies of scleroderma and liver disease, addressed known symptoms and etiologies, and the etiological relationships between these diseases, and then assessed all gathered information in context of the circumstances specific to the Veteran. The examiner explained that the ultimate conclusions were based on the specific risk factors present in the Veteran but unassociated with his service, to include the diagnosis past middle age (at 69 years old), the diagnoses of vitamin D deficiency, the association of other autoimmune disorders with genetic susceptibility, the long duration of time from exposure to diagnosis (about 50 years), and the Veteran’s exposure toxin levels well below the levels in the medical research studies. The examiner further explained that the risk factors for fatty liver disease are likely due to the Veteran’s obesity, hyperglycemia, hyperlipidemia, and race (Caucasian), which are etiologically unrelated to his service. Based on this rationale, the examiner concluded that the Veteran’s scleroderma was less likely than not (meaning probability of less than 50 percent) to have been caused by his exposure to toxins. Likewise, the examiner concluded that the Veteran’s liver disease was less likely than not to have been caused or aggravated (meaning made worse) by his scleroderma, and otherwise is unrelated to his service, to include exposure to toxins. The Board acknowledges the Appellant’s belief to the contrary, but ultimately must rely on medical evidence in this case. Absent any evidence that she has specialized training, knowledge, or experience in rendering medical opinions, the Appellant is said not to possess the requisite expertise to competently discuss etiologies of the medically complex immuno-deficiency and organic diseases, such as scleroderma and liver disease. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). This is why, particularly in this case, where the Veteran’s disabilities are medically complex and attenuated from his service by fifty years, a nexus must be established by the medical evidence. Id. For this very reason, the Board ordered and obtained a supplemental medical expert opinion which turned out negative. The Appellant has not challenged this medical opinion or provided any competent evidence to the contrary. Rather, she expressed her belief to the contrary, which undoubtedly is sincere but unfortunately lacking the requisite expertise to counterbalance the expert opinion. Accordingly, in weighing the February medical expert’s opinion that the Veteran’s scleroderma is less likely than not to have been caused by his exposure to toxins and his liver disease was less likely than not to have been caused or aggravated by his scleroderma against the Appellant’s belief to the contrary, the Board finds that the medical expert’s opinion carries more probative weight. Further considering that neither of the earlier medical opinions of record contradict the February 2019 report, the Board finds that the evidence of record weighs against the Appellant’s claim and thus service connection for scleroderma and liver disease is denied. The Board is sympathetic to the Appellant, recognizing the Veteran’s honorable service to our Nation during the Vietnam Era and the difficult circumstances imposed by his progressively debilitating disabilities until his death. Regretfully, the Board lacks any authority to grant sought benefits on an equitable basis and is ultimately bound by laws as passed by Congress. See 38 U.S.C. §§ 503, 7104; Harvey v. Brown, 6 Vet. App. 416, 425 (1994). Under VA laws, a nexus is a fundamental legal requirement for establishing an entitlement to service connection, which has not been shown in this case. As such, the criteria for establishing an entitlement to service connection have not been met. Therefore, the claim for service connection for the Veteran’s scleroderma and nonalcoholic fatty liver disease is denied. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Department of Veterans Affairs The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.