Citation Nr: 21062514 Decision Date: 10/07/21 Archive Date: 10/07/21 DOCKET NO. 14-42 217 DATE: October 7, 2021 ORDER Entitlement to service connection for Lyme disease is denied. FINDING OF FACT The Veteran has not been shown to have Lyme disease that manifested during service or is otherwise related to her military service. CONCLUSION OF LAW Lyme disease was not incurred in active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1981 to August 1987 and from June 1989 to May 2003. This case comes before the Board of Veterans' Appeals (Board) on appeal from May 2010 and August 2011 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2018, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file. In September 2018, the Board obtained an advisory medical opinion addressing the nature and etiology of the Veteran's claimed Lyme disease. In November 2018, the Veteran was provided with a copy of the opinion to review. In correspondence dated in January 2019, the Veteran indicated that she did not waive RO consideration of additional evidence added to the claims file and requested that the case be remanded to the RO for consideration of the evidence in the first instance. In March 2019, the case was remanded for the Agency of Original Jurisdiction (AOJ) to review additional evidence, including all evidence received since the October 2014 statement of the case (SOC). A supplemental statement of the case (SSOC) was issued in May 2020, and the case was returned to the Board for appellate review. Law and Analysis Neither the Veteran nor her representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Lyme disease is not an enumerated "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions based on "chronic" symptoms in service, and "continuous" symptoms since service at 38 C.F.R. § 3.303(b) do not apply here. Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran is not entitled to service connection for Lyme disease. The Veteran has contended that she developed Lyme disease in service during a field training exercise at which time she developed a rash. She has indicated that she later developed the symptoms of cold intolerance and fatigue and was then diagnosed with Reynaud's disease and glossopharyngeal neuralgia. The Veteran's service treatment records are negative for any diagnosis of Lyme disease during her active duty service. However, they do show that she sought treatment for itchiness due to a poison ivy rash in September 1989. An April 2010 VA examiner noted the reported history of tick bites and bug bites during service in the mid-1980s. However, it was noted that she did not have a Lyme-like rash at the tick bite site. She also reported tick bites in the mid-1990s and feeling ill with a fever for five days. According to the Veteran, she tested positive for Lyme disease. Her reported symptoms at that time included fatigue, exhaustion, myalgia, arthralgia, and chills. She stated that she had to stay in bed with fatigue and malaise twice per month. A physical examination did not find any signs of Lyme disease. The examiner reviewed the tests that the Veteran brought with her to the examination, which showed positive IgG for Lyme (common in the general population) and equivocal positive for Brucella (the examiner doubted any clinical significance, as she did not have any findings suggestive of brucellosis). The Veteran also had temporarily elevated complement levels with the cause unknown. Her white blood count was recently a bit low, but the cause was also unknown. The examiner stated that these laboratory tests do not show a diagnosis of Lyme disease, and the physical examination was not suggestive of Lyme disease. The complement levels were intermittently abnormal due to an unknown cause, but such findings did does not suggest Lyme disease. The Veteran was provided another VA examination in March 2011 during which reported a date of onset of 1998. She described her current symptoms as aching and fever. She stated that the condition was currently active and has been so since May 2010. However, the examiner found no underlying pathology to render a diagnosis of Lyme disease. He stated that the post-service 2009 laboratory testing showed a negative IgG study, indicating no chronic signs of Lyme disease. The examiner also explained that the Veteran would need a diagnosis from a board-certified infectious disease specialist practicing mainstream medicine and that, without one, her contention that she was diagnosed with Lyme disease is speculative. The examiner acknowledged that Dr. W.L. (initials used to protect privacy) provided a diagnosis of Lyme disease in 2009, but noted that he is an alternative physician and that his laboratory tests did not support a chronic condition because IgM was positive and IgG was negative. The examiner stated that Dr. W.L. practices alternative medicine and that it is well known that some alternative doctors believe in a chronic condition of Lyme disease that is not otherwise supported by mainstream infectious disease doctors. The Veteran submitted private medical opinions from R.M., A.V., and W.L., which all found that her laboratory results were positive for Lyme disease. She has also submitted laboratory results from August 2014, which show that she tested positive for Borrelia burgdorferi. However, in an August 2011 report from the Lyme Disease Laboratory at Stony Brook University Medical Center, her test results did not meet the Centers for Disease Control (CDC) criteria for a positive Lyme western blot. During a February 2018 hearing, the Veteran reported that the CDC confirmed that she had a documented case of Lyme disease. However, the record does not contain any formal finding from the CDC that indicates that she has Lyme disease. The Board requested a medical opinion from a Veterans Health Administration (VHA) infectious disease specialist, which was provided in September 2018. The VHA physician noted the Veteran's reported history of developing Lyme disease in service during field training exercises. He also noted that her service treatment records documented subjective complaints of itching for three days due to a poison ivy rash in September 1989. The medical provider's impression at that time was contact dermatitis. After service, the Veteran sought treatment from outside providers beginning in April 2009 and underwent several diagnostic tests intended for Lyme disease, but they were not the ones recommended and/or approved by CDC and/or FDA. The VHA physician noted that an August 2011 test at Stony Brook University Medical Center was reported as indeterminate for both IgM and IgG because the results did not meet the CDC criteria for a positive test. The same tests were run at IGeneX, Inc., in September 2012 and July 2013 and were both negative by CDC criteria. The VHA physician further explained that, although there are reports of some positive tests presumed to be associated with Lyme disease in the post-service records, they were performed at laboratories developing their own criteria and procedures for positivity and were non-FDA or CDC approved. As such, he stated that the validity of those tests cannot be ascertained. The VHA physician also stated that an individual with a longstanding history of Lyme disease is expected to have a positive IgG western blot test and IgM in the case of more recent infection. He noted that a July 2010 test at IGeneX was reported as positive for IgM by CDC criteria and negative for IgG; however, the VHA physician stated that the test could be considered as a false positive because the subsequent tests for both IgM and IgG were negative. He opined that it is unlikely that the Veteran has a diagnosis of Lyme disease based upon the available records and standardized CDC criteria and unlikely to have acquired the disease during active service. As noted above, the Veteran submitted several private medical opinions in support of the claim. According to Dr. W.L., she recalled symptoms including fatigue, cranial neuralgias, syncopal spells, cold intolerance, and myalgias during active service, but did not recall a diagnosis of Lyme disease. The service treatment records document onset of persistent fatigue and cold intolerance following concurrent rash and left knee mass in the early 1990s; recurrent left-sided face pain (trigeminal and glossopharyngeal neuralgia) and syncopal spells in the mid- to late 1990s; and treatment for chronic neck pain, left-sided extremity weakness, and cognitive impairment in the early 2000s. Dr. W.L. stated that the sequence and progression of these symptom complexes are consistent with the evolution of untreated/inadequately treated Lyme disease. Dr. W.L. discussed the laboratory test results, which he characterized as consistent with late, active Lyme disease. He also noted that, in addition to Lyme disease, the Veteran had several mild head injuries from military parachute accidents, which likely contributed to her other neurologic diagnoses of cognitive impairment, encephalopathy, scanning cerebellar speech disorder, hemi-motor ataxia syndrome, organic fatigue, and weakness. See January 2012 statement from Dr. W.L. The Veteran also submitted letters from Dr. R.M. and Dr. A.V. indicating that she is being treated for Lyme disease. However, they did not opine as to whether her claimed Lyme disease is related to active military service. See February 2018 letters from Drs. R.M. and A.V. In cases where there are conflicting statements or opinions from medical professionals, it is within the Board's province to weigh the probative value of those opinions. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (holding that the credibility and weight to be attached to medical opinions is within the province of the adjudicators). The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert's qualifications and analytical findings. See Sklar v. Brown, 5 Vet. App. 140 (1993). As long as the Board provides an adequate reason or basis for doing so, the Board does not err by favoring one competent medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). The VA benefits system does not favor the opinion of a VA examiner over a private examiner or vice versa. See 38 U.S.C. § 5125; White v. Principi, 243 F.3d 1378, 1381 (Fed. Cir. 2001) (declining to adopt the treating physician rule for adjudicating VA benefits). Regardless of the source, an examination report must minimally meet the requirement of being sufficiently complete to be adequate for the purpose of adjudicating the claim. See 38 U.S.C. § 5125; 38 C.F.R. § 4.2. In this case, the record is unclear as to whether the Veteran has a diagnosis of Lyme disease. The September 2018 VHA physician, an infectious disease specialist, explained that the positive tests for Lyme disease were not approved by the CDC and/or FDA. In addition, although the Veteran had a positive test for IgM in July 2010, the same tests were negative in 2012 and 2013, indicating that the 2010 test yielded a false positive result. Furthermore, the July 2010 test was negative for IgG, and an individual with a longstanding history of Lyme disease is expected to have a positive IgG western blot test. Similarly, the March 2011 VA examiner stated that the 2009 test results from Dr. W.L. did not support a diagnosis of Lyme disease because IgM was positive and IgG was negative. The Veteran's representative argues that the expert's conclusion that the July 2010 test yielded a false positive result is unsubstantiated. See October 2020 appellate brief. However, the Board notes that the VHA physician explained why the 2010 test was unreliable, including the difference between IgM and IgG. He clearly stated that, if the Veteran had contracted Lyme disease during service in the 1990s, she would have been expected to have a positive IgG western blot test. Moreover, even assuming that the Veteran has a current diagnosis of Lyme disease, the preponderance of the evidence does not establish a nexus to service. As previously noted, the evidence does not show that she had a Lyme-like rash at a tick bite site, and there is no evidence of treatment for or a diagnosis of Lyme disease until 2009, which was six years after her military service. Dr. W.L. stated that the Veteran's reported symptoms in service, including fatigue, cranial neuralgias, cold intolerance, and myalgias, are consistent with untreated Lyme disease. However, the March 2011 VA examiner noted that Dr. W.L. practices alternative medicine and explained that it is well known that some alternative doctors believe in a chronic condition of Lyme disease that is otherwise not supported by mainstream infectious disease doctors. The April 2010 and March 2011 VA examiners did not find any physical findings suggestive of Lyme disease. Moreover, Dr. W.L. conceded that head injuries from military parachute accidents also likely contributed to other neurologic diagnoses, including organic fatigue and weakness. The Board notes that the Veteran's current service-connected disabilities include cognitive impairment, Raynaud's syndrome, and glossopharyngeal neuralgia. Thus, her reported in-service symptoms on which Dr. W.L. relied may be attributable to causes other than Lyme disease. The Board affords substantial probative weight to the VA medical opinions, particularly the September 2018 VHA physician's opinion, as they are based on an accurate review of the claims file, to include the lay and medical evidence. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Moreover, the examiners provided reasoned explanations for the opinions with clear conclusions. In contrast, Dr. R.M. and Dr. A.V. stated that the Veteran was undergoing treatment for Lyme disease, but did not provide any nexus opinions. The Board also assigns less probative weight to Dr. W.L.'s opinion because he used laboratory tests that are not approved by CDC and/or FDA. On the other hand, the September 2018 VHA expert is a specialist in infectious diseases and provided thorough rationale for his opinions with consideration of the approved criteria and all test results of record. The Board has considered the lay statements that the Veteran's symptoms began in service and continued since that time. The Veteran is competent to report her experience and symptoms in service and thereafter. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Nevertheless, she is not competent to provide an opinion as to whether such symptoms are attributable to Lyme disease, as it is a medical determination. Indeed, such a diagnosis requires a laboratory test. The Veteran has not contended, and the evidence does not show, that she has the medical expertise to provide such opinions. See Jandreau, 492 F.3d at 1377; Layno, 6 Vet. App. at 465. Moreover, even if the Veteran were competent to determine that such symptoms were early manifestations of Lyme disease, the Board finds that the specific, reasoned opinions of the VA examiners and VHA physician are of greater probative weight than the lay assertions in this regard. As discussed above, they reviewed and considered the evidence of record, including the lay statements of record and laboratory tests, and provided medical opinions with supporting rationale relying on their medical training, knowledge, and expertise. Based on the foregoing, the Board finds that the weight of the evidence is against the Veteran's claim. As such, the benefit-of-the-doubt rule does not apply, and the claim is denied. Gilbert, 1 Vet. App. 49, 53. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D.S. Chilcote 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.