Citation Nr: 21069025 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 14-18 693 DATE: November 17, 2021 ORDER Entitlement to service connection for systemic lupus erythematosus (SLE) is granted. FINDING OF FACT The Veteran's SLE had onset during or within one year of active service. CONCLUSION OF LAW The criteria for entitlement to service connection for SLE are met. 38 U.S.C. §§ 1110, 1112, 1113, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 2000 to June 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2011 rating decision by a Department of Veterans Affairs (VA) regional office. In June 2020, the Board denied the Veteran's claim for entitlement to service connection for SLE. The Veteran appealed the denial to the United States Court of Appeals for Veterans Claims (Court). In May 2021, the Court granted a Joint Motion for Remand (JMR) in which the parties agreed that vacatur and remand of the claim was warranted. While the terms of the JMR specified that the Board should remand the claim for entitlement to service connection for SLE so that a new VA opinion could be obtained, the Veteran has since submitted evidence which supports a full grant of the matter. Accordingly, remand is not necessary. The Veteran asserts that her SLE, while not formally diagnosed until 2009, had onset during her active-duty service. Certain chronic diseases will be presumed related to service 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, 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 Veteran has a current diagnosis of SLE. See July 2011 VA Examination. SLE is an enumerated condition under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. Service treatment records show the Veteran complained of foot and knee trouble in March 2006, during active service. December 2010 STR Medical. However, the record also reflects that the Veteran's complete service treatment records are unavailable for review. See August 2011 VA Memo. In April 2007, within one year of her separation from active service, the Veteran complained of body and muscle aches for the past year. December 2010 STR Medical. In June 2009, the Veteran's husband stated that he started noticing a difference in her approximately five years before, while she was on active duty. June 2009 VA 21-4138 Statement in Support of Claim. He indicated that she used to be strong and independent, but now needed to be taken care of and could no longer enjoy her former pastimes. Id. The same month, the Veteran reported that she had been suffering from mental cloudiness and severe fatigue since 2004. The Veteran underwent VA examination in July 2011, at which time the examiner noted a diagnosis of SLE with onset in 2005, but did not provide an opinion as to the etiology of the condition. The examiner noted symptoms including malaise, fatigue, headaches, exhaustion, myalgia, and arthralgia, as well as skin symptoms with sun exposure. Negative VA opinions were provided in May 2013 January 2015, but addressed only whether the Veteran's SLE is secondary to other conditions, including parathyroidectomy, hyperparathyroidism, or Hashimoto's thyroiditis. The Veteran again underwent VA examination in March 2020. The examiner opined that SLE was less likely than not incurred in or caused by service, noting that the Veteran was diagnosed after service and there was no evidence of symptoms during service. The examiner instead indicated that the Veteran more likely had a genetic predisposition to the condition, and that, while the Veteran later complained of fatigue having an onset during service, nothing was documented in the file. In September 2021, the Veteran submitted a private opinion from Dr. J. S.-M., a Board-certified rheumatologist. October 2021 Medical Treatment Record Non-Government Facility. Dr. J. S.-M. noted the Veteran's reports of foot and knee trouble on discharge as well as her complaints of malaise and decreased muscle strength in May 2007. The clinician further noted the reports by the Veteran and her husband that mental fatigue and severe fatigue had onset in 2004, during active service. Dr. J. S.-M. opined that the Veteran's SLE at least as likely as not had onset during the course of her military service. In support of the opinion, the clinician noted that SLE affects connective joints and is often challenging to diagnose in its early stages, as symptoms, such as fatigue, can be nonspecific or mimic other conditions. The clinician further indicated that complaints of joint pain, fatigue, and cognitive issues are easily attributed to other factors and were likely overlooked during service. Following a thorough review of the file, including the lay statements of the Veteran and her spouse, as well as her complaints noted in treatment records within one year of active service, Dr. J. S.-M. opined that the Veteran's symptoms were consistent with an onset during service. While the March 2020 VA examiner provided a negative opinion, the Board affords it very little probative value. In that regard, the examiner relied largely on the lack of documentation of symptoms during service. While these are never sufficient grounds upon which to base a negative opinion, it is particularly egregious in this case where the Veteran's complete service treatment records have been noted to be unavailable. Further, the Veteran did complain of joint pain during service and provided credible lay statements regarding the onset of her symptoms. Conversely, the March 2021 private opinion is based on a thorough review of the record and provides a sufficient explanation for the opinion stated. Upon review, the Board finds the evidence is at least in relative equipoise as to whether the Veteran's SLE had onset in or within one year of active service. In that regard, the Veteran has credibly testified to symptoms including fatigue, cognitive decline, and joint pain during service. Post-service treatment records show that she continued to complain of these symptoms during the applicable presumptive period, and for years after. As clinicians have since attributed these symptoms to the Veteran's SLE, continuity of symptomatology is established. Accordingly, resolving the benefit of the doubt in the Veteran's favor, service connection is warranted and the claim is granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. J. B. FREEMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. D. Bruce, 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.