Citation Nr: 20065713 Decision Date: 10/08/20 Archive Date: 10/08/20 DOCKET NO. 16-48 911 DATE: October 8, 2020 ORDER Entitlement to service connection for acquired hemophilia (claimed as hemic-lymphatic condition) is denied. Entitlement to service connection for lymph node cancer is denied. Entitlement to service connection for a thyroid disability is denied. REMANDED Entitlement to an initial compensable rating for a left knee disability is remanded. Entitlement to an initial compensable rating for a right knee disability is remanded. Entitlement to a compensable rating for bilateral hearing loss is remanded. FINDINGS OF FACT 1. The Veteran’s acquired hemophilia was not clinically evident during his active service or for many years thereafter and the most probative evidence establishes that the Veteran’s current acquired hemophilia is not causally related to an in-service disease or injury. 2. The Veteran’s lymph node cancer was not clinically evident during his active service or for many years thereafter and the most probative evidence establishes that the Veteran’s current lymph node cancer is not causally related to an in-service disease or injury. 3. The Veteran’s thyroid disability was not clinically evident during his active service or for many years thereafter and the most probative evidence establishes that the Veteran’s current thyroid disability is not causally related to an in-service disease or injury. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for acquired hemophilia have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for lymph node cancer have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for entitlement to service connection for a thyroid disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1998 to November 2002. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from January 2012 and April 2015 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO), which, inter alia, granted service connection for left and right knee disabilities and assigned noncompensable ratings, effective March 21, 2011, continued the noncompensable rating for bilateral hearing loss, and denied service connection for acquired hemophilia, lymph node cancer, and a thyroid disability, respectively. In April 2020, the Veteran testified at a virtual hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The Board notes that the Veteran’s Notice of Disagreement also included the issues of entitlement to service connection for psychosis for the purpose of establishing eligibility for treatment under 38 U.S.C. § 1702 and entitlement to service connection for a left ankle disability. These issues were included in the September 2016 Statement of the Case (SOC). As the Veteran’s VA Form 9 indicated that he wished to limit his appeal to the issues discussed immediately above, the issues of entitlement to service connection for psychosis for the purpose of establishing eligibility for treatment under 38 U.S.C. § 1702 and entitlement to service connection for a left ankle disability are not before the Board on appeal. The Board also observes that following the issuance of the statement of the case (SOC) for the pending appeal, and after this matter was certified to the Board, additional medical records were associated with the Veteran’s electronic claims file. The Board notes that the updated treatment records are duplicative and not relevant to the Veteran’s current claims. Therefore, this evidence is not pertinent to the Veteran’s current issues addressed below and remand for initial agency of original jurisdiction (AOJ) review is not required. See 38 C.F.R. § 19.37(a) (requiring remand for a supplemental statement of the case (SSOC), unless the additional evidence duplicates evidence previously of record which was discussed in the SOC or SSOC or the additional evidence is not relevant to the issue on appeal). The Board also notes that after the appeal was certified and transferred to the Board, the Veteran submitted additional evidence, to include medical treatises and internet research, which was associated with the Veteran’s electronic claims file. Since the Veteran has waived RO consideration, AOJ review is not required. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain specifically enumerated chronic diseases, including malignant tumors, will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for acquired hemophilia is denied. 2. Entitlement to service connection for lymph node cancer is denied. 3. Entitlement to service connection for a thyroid disability is denied. The Veteran contends that his acquired hemophilia, lymph node cancer, and thyroid disability are the result of in-service exposure to toxic chemicals, to include solvents used to clean engine parts, motor oil, diesel fuel, and Purple K. Alternatively, the Veteran contends that during active duty he experienced symptoms which could be attributed to a Helicobacter pylori (H. pylori) infection and that this infection could have led to his development of lymphoma. The Veteran also contends that he may have been exposed to radiation during active duty, which could have contributed to the development of his thyroid disability. See April 17, 2020 Transcript of Hearing, pages 3-7; see also May 2020 Attorney Brief. Service treatment records (STRs) are negative for complaints, observations, or treatment regarding vascular, lymphatic, or endocrine disabilities. At his August 2002 separation examination, clinical evaluation of his vascular, lymphatic, and endocrine systems was normal. See August 2002 Report of Medical Examination. The Veteran’s service personnel records reflect that his military occupational specialty was landing support specialist. His military education included hazardous material handling. A May 2014 VA treatment record noted that the Veteran was being treated for a Factor VII receptor deficiency. It was also noted that the Veteran was found to have mediastina and axillary lymphadenopathy and the working diagnosis was lymphoma. A PET/CT scan revealed a hyper metabolic thyroid nodule on the left, measuring 3 x 3 cm. The Veteran reported no radiation exposure, however, he indicated that he worked with hazardous chemicals during his military service in the U.S. and Japan. See May 2014 Endocrinology Note. In support of his claim, the Veteran submitted a Disability Benefits Questionnaire (DBQ) completed by a VA oncologist, Dr. G.H. The physician noted an April 2014 diagnosis of acquired hemophilia and a September 2014 partial thyroidectomy. The physician also noted a diagnosis of persistent lymphadenopathy. The physician indicated that the cause of the Veteran’s acquired hemophilia was unknown, although he opined that the resected Hurthle cell adenoma or lymphoma remained possible underlying etiologies. See September 2014 DBQ completed by Dr. G.H. The DBQ contained no indication that the Veteran’s diagnosed disabilities were causally related to an in-service disease or injury, to include exposure to environmental hazards or an in-service infection. At the April 2020 Board hearing, referenced above, the Veteran testified that his acquired hemophilia, lymph node cancer, and thyroid disability were the result of in-service exposure to toxic chemicals. He testified that his secondary MOS was hazardous cleanup and therefore he handled toxic chemicals, to include diesel fuels, motor oils, gasoline, fire extinguisher contents, known as Purple K, and solvents used to clean engine parts, among others. He further testified that his doctors could not confirm or deny whether his lymph node or thyroid disabilities were related to his active duty because his case was rare. See April 17, 2020 Transcript of Hearing, pages 3-7. In support of his claim, the Veteran also submitted medical treatises pertaining to lymphoma regarding symptoms and potential causes, which some studies have shown may include exposure to certain chemicals, such as benzene, and certain herbicides and insecticides. Additionally, the Veteran provided internet research regarding H. pylori and potential complications associated with such, to include ulcers, inflammation of the stomach lining, and stomach cancer, as well as articles pertaining to Cooperation Afloat Readiness and Training (CARAT) and Operation Bright Star. See medical treatises and internet research received May 2020. Although the Veteran has not been afforded VA examinations in connection with these claims, the Board finds that examinations are not necessary. There is no indication that the Veteran’s acquired hemophilia, lymph node cancer, or thyroid disability had their inception during active service or within the first post-service year or that any currently claimed disability is otherwise related to the Veteran’s active duty, to include his reported exposure to environmental hazards such as solvents used to clean engine parts, motor oil, diesel fuel, and Purple K, or an H. pylori infection, and the record contains no indication of in-service exposure to ionizing radiation. A mere conclusory generalized lay statement that service event or illness caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010). Absent any indication that the Veteran’s acquired hemophilia, lymph node cancer, or thyroid disability had their inception during active service or within the first post-service year or that any currently claimed disability is otherwise related to an established in-service disease or injury, the Board finds that examinations are not necessary. In short, there is no competent and probative evidence that the Veteran’s acquired hemophilia, lymph node cancer, or thyroid disability were incurred during active service. As indicated above, there is no evidence that the Veteran suffered from injury or disease of his vascular, lymphatic, or endocrine systems during active service. Significantly, there is no evidence to suggest that the Veteran was diagnosed with acquired hemophilia, lymph node cancer, or a thyroid disability for years after his separation from active service, and the Veteran has not contended otherwise. Notably, VA treatment records dated in May 2014 noted a Factor VII receptor deficiency, lymphoma, and a hyper metabolic thyroid nodule. Moreover, the evidence of record does not demonstrate that the Veteran had continuous vascular, lymphatic, or endocrine symptoms following his November 2002 separation from active service. Additionally, the Board finds that the record contains no indication that the Veteran’s acquired hemophilia, lymph node cancer, or thyroid disability are otherwise causally related to his active service or caused or aggravated by a service-connected disability. In that regard, no medical professional has suggested that the Veteran suffers from vascular, lymphatic, or endocrine disabilities that are related to his military service, and neither the Veteran nor his attorney has presented or identified the existence of any such medical evidence or opinion. In fact, in the September 2014 DBQ, the Veteran’s VA physician, Dr. G.H., indicated that the cause of the Veteran’s acquired hemophilia was unknown. Additionally, the Veteran testified at the April 2020 Board hearing, noted above, that his doctors could not confirm or deny whether his lymph node cancer or thyroid disability were related to his active duty because his case was rare. While the Board acknowledges the Veteran’s contentions that his disabilities were caused by active service, the Board finds that he is not competent to determine the etiology of his disabilities as this would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the Veteran in this case, who has not been shown by the evidence of record to have medical training or skills. See Layno v. Brown, 6 Vet. App. 465, 470 (1994); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Although the Veteran’s attorney argues that the Veteran’s claims were incorrectly decided because “the VA has not shown that it is as less likely as not that the Veteran’s cancer is linked to his period of active military service,” the Board notes that the Veteran’s attorney has applied an incorrect standard of proof. The Veteran’s attorney is reminded that it is a claimant’s responsibility to support a claim for VA benefits, including submitting or specifically identifying relevant evidence and alleging specific errors of fact or law. See 38 U.S.C. §§ 5107(a), 7105(d)(5). Counsel are expected to present arguments they deem material and relevant to their clients’ cases. See e.g. Andrews v. Nicholson, 421 F.3d 1278, 1282 (Fed. Cir. 2005) (pro se pleadings, not those of counsel, are entitled to a sympathetic reading). Based on the foregoing, as the probative evidence is against the Veteran’s claims for service connection for acquired hemophilia, lymph node cancer, and a thyroid disability, the benefit-of the-doubt rule is not for application. See 38 U.S.C. § 5107, 38 C.F.R. § 3.102. Accordingly, the Board finds that the elements of service connection are not met, and the Veteran’s claims for acquired hemophilia, lymph node cancer, and a thyroid disability are denied. REASONS FOR REMAND 1. Entitlement to an initial compensable rating for a left knee disability is remanded. 2. Entitlement to an initial compensable rating for a right knee disability is remanded. The Veteran contends that his left and right knee disabilities are more severe than currently rated. See April 17, 2020 Transcript of Hearing, pages 8-11. The Veteran was most recently afforded a VA examination in April 2016 to determine the severity of his left and right knee disabilities. At the April 2020 Board hearing, noted above, the Veteran testified that his left and right knee disabilities had worsened since he was last examined for VA compensation purposes. He indicated that he experienced painful kneecaps and that his knees locked and popped. Additionally, the Veteran indicated that his knees gave out with prolonged standing. As such, upon remand, the Veteran should be afforded a new VA examination to assess the current severity of his left and right knee disabilities. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). 3. Entitlement to a compensable rating for bilateral hearing loss is remanded. The Veteran contends that his bilateral hearing loss is more severe than currently rated. See April 17, 2020 Transcript of Hearing, pages 12, 13. The Veteran was most recently afforded a VA examination in April 2016 to determine the severity of his bilateral hearing loss. At the April 2020 Board hearing, referenced above, the Veteran testified that his bilateral hearing had worsened since he was last examined for VA compensation purposes. He indicated that “speech [wa]s really muttered for conversation, loud noises” and that he wore hearing aids “semi-regularly.” As such, upon remand, the Veteran should be afforded a new VA examination to assess the current severity of his bilateral hearing loss. See Snuffer, 10 Vet. App. 400; Caffrey, 6 Vet. App. 377. Accordingly, the matters are REMANDED for the following action: 1. The Veteran should be afforded a VA medical examination to evaluate the current severity of his service-connected left and right knee disabilities. Access to the Veteran’s electronic VA claims file must be made available to the examiner for review in connection with the examination. After examining the Veteran and reviewing the record, the examiner should identify all symptoms and pathology associated with the service-connected left and right knee disabilities, to include any loss of motion, meniscal pathology, instability, or subluxation. The examiner should consider the Veteran’s April 2020 hearing testimony, which describes the Veteran’s knee pain and other associated symptomatology, to include popping, locking, and lateral instability. The examiner should test for both active and passive motion, as well as weight-bearing and non-weight bearing. The examiner should comment on the severity of any painful motion or weakness. The examiner should also provide range of motion measurements, including at what point in the arc of motion pain limits function both regularly and during any flare-ups, even if a flare-up is not observed on that day. In addressing the nature of any disability during a flare-up the examiner must address the severity of the flare-up, the frequency and duration of the flare-up, and all precipitating and alleviating factors 2. Afford the Veteran a VA medical examination to ascertain the current severity of his bilateral hearing loss. Access to the Veteran’s VA claims file should be made available to the examiner for review in connection with the examination. All necessary tests should be conducted and all findings reported in detail. K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Ruddy, Associate Counsel 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.