Citation Nr: 21070570 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 18-25 996 DATE: November 24, 2021 ORDER New and material evidence having been received, reopening of the previously denied claim of service connection for chronic liver disease is granted. A disability rating of 10 percent, but no higher, for the service-connected seborrheic dermatitis is granted for the period on appeal prior to September 7, 2015 and from November 9, 2019, to include restoration of the previously assigned 10 percent rating effective from November 9, 2019, is granted. A disability rating in excess of 10 percent for the service-connected seborrheic dermatitis for the period on appeal from September 7, 2015 through November 8, 2019, is denied. REMANDED Service connection for chronic liver disease, to include cirrhosis and status post liver transplant and as due to environmental contaminants associated with Southwest Asia service, is remanded. FINDINGS OF FACT 1. In a May 2017 rating decision, the RO denied service connection for chronic liver disease. The Veteran was notified of the decision in May 2017. However, the Veteran did not file a Notice of Disagreement (NOD) within one year of notification of the decision. 2. Evidence submitted since the May 2017 rating decision was not previously of record and relates to unestablished facts necessary to substantiate the claim of service connection for chronic liver disease. 3. The preponderance of the evidence does not demonstrate sustained improvement in the Veteran's seborrheic dermatitis during the period from November 9, 2019 onward. 4. For the entire period on appeal the Veteran's seborrheic dermatitis has covered at least 5 percent and no more than 20 percent of total body and exposed areas and has been treated with no more than topical corticosteroid therapy not affecting the body as a whole. CONCLUSIONS OF LAW 1. The May 2017 rating decision that denied the claim of service connection for chronic liver disease is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. Evidence received since the May 2017 rating decision is new and material and sufficient to reopen the claim of service connection for chronic liver disease. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The criteria for a disability rating of 10 percent, but not higher, for the service-connected seborrheic dermatitis have been met for the entire period on appeal prior to September 7, 2015 and from November 9, 2019 onward. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.20, 4.118, Diagnostic Code 7806. 4. The reduction of the disability rating for the Veteran's service-connected seborrheic dermatitis from 10 percent to noncompensable was not proper and the 10 percent disability rating is restored from November 9, 2019. 38 U.S.C. § 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.105, 3.344(c), 4.118, Diagnostic Code 7806. 5. The criteria for a disability rating in excess of 10 percent for the service-connected seborrheic dermatitis for the period on appeal from September 7, 2015 through November 8, 2019, have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.20, 4.118, Diagnostic Code 7806. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1990 to May 1991, with additional service in the U.S. National Guard. This case is before the Board of Veterans' Appeals (Board) on appeal from April 2015 and November 2018 Department of Veterans Affairs (VA) Regional Office (RO) rating decisions. In the April 2015 decision, the RO denied a compensable disability rating for the service-connected seborrheic dermatitis. In May 2015, VA received the Veteran's NOD. In an April 2018 rating decision, the RO increased the disability rating for the seborrheic dermatitis from noncompensable to 10 percent, effective September 7, 2015. Furthermore, the RO also issued a Statement of the Case (SOC) in April 2018. Later that month, VA received the Veteran's VA Form 9 appeal to the Board. In the November 2018 rating decision, the RO denied reopening of the claim for service connection for chronic liver disease because the evidence submitted was not new and material. In December 2018, VA received the Veteran's NOD. In February 2020, the RO issued a SOC. In February 2020, VA received the Veteran's VA Form 9 appeal to the Board. During the pendency of the appeal, the RO issued a March 2020 rating decision reducing the disability rating for the service-connected seborrheic dermatitis from 10 percent to noncompensable, effective November 9, 2019. In July 2021, the Veteran testified at a video conference hearing at the RO before the undersigned Veterans Law Judge (VLJ). A transcript of that testimony is of record. New and Material Evidence 1. Whether new and material evidence has been received sufficient to reopen the previously denied claim of service connection for chronic liver disease. After a decision becomes final, a claimant must present new and material evidence to reopen the previously denied claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). New evidence is evidence not previously submitted to agency decision makers. Material evidence, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence cannot be cumulative or redundant of the evidence of record at the time of the last prior final denial and must raise a reasonable probability of the substantiating the claim. 38 C.F.R. § 3.156(a). The provisions of 38 U.S.C. § 5108 require a review of all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened. See Evans v. Brown, 9 Vet. App. 273, 282-83 (1996). Newly submitted evidence is generally presumed to be credible for the purposes of reopening a claim. Justus v. Principi, 3 Vet. App. 510, 513 (1992). New and material evidence is not required for each previously unproven element of a claim. Shade v. Shinseki, 24 Vet. App. 110, 120 (2010). The threshold for determining whether evidence raises a reasonable possibility of substantiating a claim is low. Id. at 117-18. In July 2016, VA received the Veteran's original claim for service connection for chronic liver disease. In a May 2017 rating decision, the RO denied service connection for chronic liver disease. The basis for the denial was that the chronic liver disease was not related to an in-service event, disease, or injury. The Veteran was notified of the decision in May 2017. However, he did not appeal the decision or submit new and material evidence within one year of notification of the decision. Therefore, the May 2017 rating decision became final. 38 U.S.C. § 7105; 38 C.F.R. §§ 19.52, 20.1103. In October 2018, VA received a new claim for service connection for chronic liver disease. In a November 2018 rating decision, the RO denied reopening of the claim for service connection for chronic liver disease because new and material evidence had not been received. The evidence of record at the time of the May 2017 rating decision included service treatment records (STRs), VA treatment records, private treatment records, and an April 2017 VA examination report. The evidence received since the May 2017 rating decision includes the July 2021 Board hearing transcript, additional VA and private treatment records, medical literature submitted by the Veteran, and February 2020 and February 2021 VA examination reports. The evidence received after the May 2017 rating decision relates to a reason for the prior denial, and therefore relates to unestablished facts necessary to substantiate the claim and is not cumulative or redundant. Therefore, the new evidence is material, and reopening of the claim for service connection for chronic liver disease is warranted. The reopened claim is addressed in the REMAND section below. Rating Reduction 2. The propriety of the rating reduction for the service-connected seborrheic dermatitis from 10 percent to noncompensable. In general, prior to reducing a veteran's disability rating, VA is required to comply with pertinent VA regulations applicable to all rating reduction cases, regardless of the rating level or the length of time that the rating has been in effect. When reduction in the rating of a service-connected disability is contemplated and the lower evaluation would result in a reduction or discontinuance of compensation payments, a rating decision proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons. The beneficiary must be notified at his or her latest address of record of the contemplated action and furnished detailed reasons thereof. The beneficiary must be given 60 days for the presentation of additional evidence to show that compensation payments should be continued at the present level. 38 C.F.R. § 3.105(e). In the advance written notice, the beneficiary will be informed of his or her right for a pre-determination hearing, and if a timely request for such a hearing is received (i.e., within 30 days), benefit payments shall be continued at the previously established level pending a final determination. 38 C.F.R. § 3.105(i)(1). In certain rating reduction cases, VA benefits recipients are to be afforded greater protections, set forth in 38 C.F.R. § 3.344. Rating agencies will handle cases affected by change of medical findings or diagnosis, to produce the greatest degree of stability of disability evaluations consistent with the laws and VA regulations governing disability compensation and pension. These considerations apply to ratings that have continued for long periods at the same level (five years or more), and not to DJD that have not become stabilized and are likely to improve. See Brown v. Brown, 5 Vet. App. 413, 418 (1993). Notably, 38 C.F.R. § 3.344(a) requires that the disability in question has materially improved, and that it is reasonably certain that such improvement will be maintained under the ordinary conditions of life. Nonetheless, for both reductions of disability ratings in place for less than 5 years and 5 years or more and irrespective of § 3.344(a), Brown requires that the disability in question reflects: (1) actual improvement in the disability and (2) that improvement reflects improvement in the ability to function under the ordinary conditions of life and work. See id. at 421; see also Stern v. McDonough, 34 Vet. App. 51 (2021). VA regulation 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history. Similarly, 38 C.F.R. § 4.2 establishes that "[i]t is the responsibility of the rating specialist to interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present." These provisions impose a clear requirement that VA rating reductions, as with all VA rating decisions, be based upon review of the entire history of the veteran's disability. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Furthermore, VA regulation 38 C.F.R. § 4.13 provides that the rating agency should assure itself that there has been an actual change in the condition, for better or worse, and not merely a difference in the thoroughness of the examination or in use of descriptive terms. Pursuant to these provisions, the RO and Board are required in any rating reduction case to ascertain, based upon review of the entire recorded history of the condition, whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based upon thorough examinations. See Schafrath, 1 Vet. App. at 594 ("these requirements for evaluation of the complete medical history of the claimant's condition operate to protect claimants against adverse decisions based on a single, incomplete or inaccurate report and to enable VA to make a more precise evaluation of the level of disability and of any changes in the condition."). Finally, 38 C.F.R. § 4.10 establishes that "[t]he basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment" and 38 C.F.R. § 4.2 directs that "[e]ach disability must be considered from the point of view of the veteran working or seeking work." Thus, in any rating reduction case not only must it be determined that an improvement in a disability has actually occurred but also that that improvement actually reflects an improvement in the veteran's ability to function under the ordinary conditions of life and work. See Brown, 5 Vet. App. at 421. A claim as to whether a rating reduction was proper must be resolved in the Veteran's favor unless the Board concludes that a fair preponderance of evidence weighs against the claim. Id. When a reduction is effectuated without following the applicable regulations, to include procedural and substantive provisions, the reduction is void ab initio. See Greyzck v. West, 12 Vet. App. 288, 292 (1999). In this case, the rating reduction for the service-connected seborrheic dermatitis did not result in a decrease to the Veteran's overall compensation. As such, the RO was not required to submit a rating decision proposing the reduction prior to implementing the reduction. 38 C.F.R. § 3.105(e). Furthermore, the effective date of the rating reduction November 9, 2019 was within 5 years of the increase of the rating for seborrheic dermatitis from noncompensable to 10 percent, effective September 7, 2015. Therefore, the provisions of 38 C.F.R. § 3.344, pertaining to stabilization of disability ratings, do not apply in this appeal. The narrative portion of the March 2020 rating decision that reduced the rating for the seborrheic dermatitis concluded only that a November 2019 VA dermatological skin examination showed "an improvement" in the seborrheic dermatitis. However, neither the March 2020 rating decision nor any other decision by the RO during the period on appeal has addressed whether the seborrheic dermatitis had had actually improved such that the improvement reflects improvement in the ability to function under the ordinary conditions of life. See Brown, 5 Vet. App. at 418; see also Stern, 34 Vet. App. at 51. In this case, the preponderance of the evidence does not show that the seborrheic dermatitis had actually improved such that the improvement reflects improvement in the ability to function under the ordinary conditions of life. In this regard, during the July 2021 Board hearing, the Veteran testified that his seborrheic dermatitis appears "every six months, when it's very, very hot." July 2021 Board hearing transcript at 5. Furthermore, he reported that the dermatitis was manifested by red areas on the chest, brown spots on the head, and purple, black, and grey spots on both elbows; affected areas were itchy, scaly, and sensitive to touch. See id. Given the extensive dermatological records submitted by the Veteran, which include photographs of the affected areas, there is no reason to doubt the Veteran's testimony about his seasonal symptoms. Furthermore, as the Veteran's most recent VA examination occurred in November, less probative value is assigned to that examination. In conclusion, the reduction in this case was not proper and restoration of the 10 percent rating for the service-connected seborrheic dermatitis is warranted, effective from November 9, 2019. Increased Rating 3. Entitlement to a compensable disability rating for the service-connected seborrheic dermatitis for the period on appeal prior to September 7, 2015. 4. Entitlement to a disability rating in excess of 10 percent for the service-connected seborrheic dermatitis for the period on appeal from September 7, 2015. The Veteran's seborrheic dermatitis is currently rated as 10 percent disabling under 38 C.F.R. § 4.118, Diagnostic Code 7806. Under Diagnostic Code 7806, dermatitis or eczema is evaluated under the General Rating Formular for the Skin. VA recently amended the rating criteria for skin conditions, effective August 13, 2018. See 83 Fed. Reg. 32,597 (July 13, 2018); 83 Fed. Reg. 38,663 (Aug. 7, 2018). In cases where rating criteria are amended during the course of the appeal, the Board must consider both the former and current schedular criteria. If an increased rating is warranted under new, revised criteria, the award may not be made effective before the effective date of the change. See Kuzma v. Principi, 341 F.3d 1327, 1328 (Fed. Cir. 2003). Under the prior regulations, the General Rating Formula for the Skin provided for a noncompensable disability rating when dermatitis or eczema involves less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and no more than topical therapy has been required during the past 12-month period. A 10 percent rating is warranted when affecting at least 5 but less than 20 percent of the entire body, or at least 5 percent but less than 20 percent of exposed areas; or where intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is warranted when 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected; or where systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating was warranted when more than 40 percent of the entire body or more than 40 percent of exposed areas are affected; or where constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs are required during the past 12-month period. The Federal Circuit addressed the meaning of "systemic" and "topical" for rating skin disabilities under the regulatory criteria prior to August 31, 2018. See Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). For these purposes, systemic therapy means treatment pertaining to or affecting the body as a whole, whereas topical therapy means treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied. Id. at 1355. The Federal Circuit acknowledged that a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, but the Court emphasized that this possibility does not mean that all applications of topical corticosteroids amount to systemic therapy. Id. Rather, the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the facts of each case. Id. at 1356. Under the revised VA regulations, it is explicitly stated that for the purposes of the skin disability ratings, "systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin." 38 C.F.R. § 4.118(a). Additionally, a new General Rating Formula for the Skin applies to Diagnostic Codes 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824. Under this formula, a maximum 60 percent rating requires at least one of the following: (1) characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or (2) constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. A 30 percent rating requires at least one of the following: (1) characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or (2) systemic therapy such as those listed under the 60 percent criteria required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. Id. A 10 percent rating requires at least one of the following: (1) characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or (2) at least 5 percent, but less than 20 percent, of exposed areas affected; or (3) intermittent systemic therapy such as those listed under the 60 percent criteria required for a total duration of less than 6 weeks over the past 12-month period. Id. A noncompensable (0 percent) rating is assigned where there is no more than topical therapy required over the past 12-month period and at least one of the following: (1) characteristic lesions involving less than 5 percent of the entire body affected; or (2) characteristic lesions involving less than 5 percent of exposed areas affected. Id. The General Rating Formula for the Skin, as it pertains to Diagnostic Code 7806, also indicates that the disability may be rated as disfigurement of the head, face or neck (under Diagnostic Code 7800) or as a scar (under Diagnostic Codes 7801, 7802, 7804, or 7805), depending upon the predominant disability. Under Diagnostic Code 7800, a scar of the head, face, or neck with one characteristic of disfigurement is rated as 10 percent disabling. A 30 percent rating is assigned for visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement. A 50 percent rating is assigned when there is visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement. An 80 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800. The 8 characteristics of disfigurement, for the purposes of evaluation under § 4.118, Diagnostic Code 7800, are: (1) scar 5 or more inches (13 or more centimeters) in length; (2) scar at least one-quarter inch (0.6 centimeters) wide at widest part; (3) surface contour of scar elevated or depressed on palpation; (4) scar adherent to underlying tissue; (5) skin hypo- or hyper-pigmented in an area exceeding six square inches 39 square centimeters); (6) skin texture abnormal (irregular, shiny, scaly, etc.) in an area exceeding six square inches (39 square centimeters); (7) underlying soft tissue missing in an area exceeding six square inches (39 square centimeters); and (8) skin indurated and inflexible in an area exceeding six square inches (39 square centimeters). Id. at Note (1). The characteristic(s) of disfigurement may be caused by one scar or by multiple scars; the characteristic(s) required to assign a particular evaluation need not be caused by a single scar in order to assign that evaluation. Id. at Note (5). As noted above in the "Rating Reduction" section, the November 2019 VA examination did not occur during a flare of the seborrheic dermatitis. However, the evidence does not show that the seborrheic dermatitis has worsened since the previous September 2018 VA examination. Accordingly, given also that the Veteran competently testified as to the current state of his symptoms during the recent July 2021 Board hearing, no additional development is warranted for the issue of increased rating for the service-connected seborrheic dermatitis. During the period on appeal, the Veteran received an initial VA examination for his seborrheic dermatitis in June 2015. The examiner noted that the Veteran had been treated with constant/near-constant use of corticosteroids Hydrocortisone for 6 weeks or more, but not constant, within the past 12 months. At the time of examination, the seborrheic dermatitis covered more than 5 percent but less than 20 percent of total body and exposed areas. May 2017 private dermatological records show that the Veteran displayed the following dermatological symptoms: "light tan macules in sun distribution on the face and trunk"; "pink/orange scaly plaques distributed on the left medial inferior chest, left superior parietal scalp, and left medial frontal scalp"; "patch and macule located on the right nasal labial, upper [and] distributed on the body throughout and left inferior medial malar cheek"; erythematous patches with hyperkeratotic scale distributed on the left superior occipital scalp, posterior mid-parietal scalp, right superior occipital scalp, and right superior parietal scalp"; "bright cherry-red papules distributed on the left medial inferior chest and trunk"; stuck-on, worty, greasy brown papule with pseudo-horn cysts distributed on the left lateral upper back, right superior lateral upper back, left superior medial midback, inferior thoracic spine, left lateral superior chest, left clavicular neck, and left superior medial upper back"; and "patch and macule located on the right elbow." There was no indication of scarring related to the Veteran's dermatological symptoms. In the September 2018 examination report, the examiner indicated that the Veteran had been treated constant/near-constant use of corticosteroids Hydrocortisone the past 12 months. Furthermore, the examiner recorded treatment with a special shampoo Ketoconasole. At the time of examination, the seborrheic dermatitis covered less than 5 percent of total body and exposed areas. The examiner found that the seborrheic dermatitis did not result in scarring or disfigurement of the head, face, or neck. Finally, the examiner noted that the Veteran would be restricted from performing work that would require him to work in the sun. Based on the foregoing, a disability rating of 10 percent for the service-connected seborrheic dermatitis is warranted for the entire period on appeal, or from December 30, 2014, the date of Veteran's December 2014 informal claim for increase. Specifically, there is no reason to doubt the Veteran's credible statements about his symptoms during the entire period on appeal, and these statements are consistent with the results of the June 2015 examination. Therefore, as of the Veteran's December 30, 2014 informal claim, and resolving reasonable doubt in the Veteran's favor, the Veteran's seborrheic dermatitis was manifested by symptoms more closely approximating at least 5 but less than 20 percent of the entire body and at least 5 percent but less than 20 percent of exposed areas. Accordingly, the criteria for a 10 percent rating for the seborrheic dermatitis as of December 30, 2014, or for the entire period on appeal, have been met. However, a disability rating in excess of 10 percent for the service-connected seborrheic dermatitis is not warranted at any time during the period on appeal. First, there is no evidence of scarring or disfigurement due to the seborrheic dermatitis. Next, there is no evidence that the seborrheic dermatitis covered 20 percent or more of total body or exposed areas during the period on appeal. Finally, although the May 2017 examiner noted constant/near constant use of a corticosteroid within the past 12 months, the evidence shows that the use of the topical hydrocortisone did not constitute systemic therapy affecting the body as a whole. Importantly, whether a topical therapy is systemic in nature is a factual finding that may be made by the Board. See Burton v. Wilkie, 30 Vet. App. 286, 291-292 (2018). In addition, the evidence reveals that the Veteran has developed a neoplasm on the left lateral neck, for which he received a shave biopsy most recently in 2019. See September 2019 VA examination report; private dermatological records dated May 1, 2017. However, the neoplasm on the left lateral neck constitutes a disability that is separate and distinct from the seborrheic dermatitis and may not be factored into the evaluation for seborrheic dermatitis. Given the above, the criteria for a disability rating in excess of 10 percent for the seborrheic dermatitis under the prior regulations and the new General Rating formula for the skin have not been met at any time during the period on appeal. REASONS FOR REMAND 1. Entitlement to service connection for chronic liver disease, to include to include cirrhosis and status post liver transplant claimed as due to environmental contaminants associates with Southwest Asia service. As noted above, the Veteran believes that he developed chronic liver disease as a result of exposure to environmental contaminants while stationed in Southwest Asia. He claims that his deployment to Saudi Arabia exposed him to environmental hazards associated with the region and believes that he developed chronic liver disease as a result. See April 2017 VA examination report. Specifically, the Veteran asserts that he escorted "dozens of POWs [prisoners of war] from Iraq to Saudi Arabia" and was required "to check enemy/friendly vehicles destroyed on the side of the road." December 2018 NOD. For veterans with service in the Southwest Asia theater of operations during the Persian Gulf War, service connection may also be established under 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Under that statute and regulation, service connection may be warranted for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more no later than December 31, 2021. (This date has since been extended to December 31, 2026 per a VA-promulgated interim final rule. See 86 FR 57000 (September 14, 2021)). The term Southwest Asia theater of operations refers to Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(e)(2). The Veteran's DD Form 214 reflects that the Veteran received the Southwest Asia Service Medal for his period of active service. Furthermore, in the "Remarks" section, the DD Form 214 states that the Veteran served in Southwest Asia in support of Operation Desert Shield/Desert Storm from January 23, 1991 to May 6, 1991. Accordingly, service in Southwest Asia is verified. Additionally, the DD Form 214 lists the Veteran's military occupational specialty (MOS) as military policeman. For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness (MUCMI); and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service-connection. Under 38 C.F.R. § 3.317, a MUCMI means a diagnosed illness without conclusive pathophysiology and, or alternatively, without conclusive etiology i.e., cause, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). Along with the three examples of a MUCMI provided by section 1117(a)(2)(B), CFS, fibromyalgia, and functional gastrointestinal disorder including irritable bowel syndrome (IBS), there is a list of signs or symptoms that may be a manifestation of an undiagnosed illness or a MUCMI that includes fatigue, gastrointestinal signs or symptoms, signs or symptoms involving the respiratory system, muscle pain, joint pain, and sleep disturbances. 38 U.S.C. § 1117(g); 38 C.F.R. § 3.317(b). The term "objective indications of a qualifying chronic disability" includes both "signs," in a medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). In the case of claims based on undiagnosed illness under 38 U.S.C. § 1117, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Although the Veteran is not medically trained, he is competent to report the observable manifestations of his claimed disorders. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Hence, his own assertions may serve as support for the presence of symptoms. For purposes of Gulf War undiagnosed illness claims, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(2)(5). Initially, the Veteran was diagnosed with chronic liver disease in approximately 2009. See April 2017 VA examination report. The April 2017 examiner identified symptoms of fatigue and thrombocytopenia (low platelet count) as associated with the chronic liver disease. Furthermore, a February 2020 examiner noted symptoms of swollen belly, abdominal pain, and weight loss. No etiology has ever been identified for the Veteran's chronic liver disease. In an April 2017 VA Gulf War Medical Examination Report, the examiner provided a diagnosis of "chronic liver disease of unknown etiology (with secondary thrombocytopenia & fatigue)" and explicitly identified the chronic liver disease as a diagnosable but MUCMI of unknown etiology. See also February 2021 VA examination report. Nonetheless, the April 2017 examiner provided no rationale for the conclusion that the Veteran's chronic liver disease is a MUCMI, and his disability is shown to be consistent with laboratory findings and symptoms. In other words, the Veteran's symptoms are not unexplained. Furthermore, while indicating that the chronic liver disease was a MUCMI and that his thrombocytopenia and fatigue were secondary to the liver disease, the examiner also opined that the condition is not caused by or a result of a specific exposure event during service in Southwest Asia because thrombocytopenia and fatigue have been identified to be secondary to chronic liver disease, and his condition did not develop until many years following discharge from service. This makes it unlikely that an etiologic link exists between the current disability and service. Similarly, however, a February 2020 examiner noted that the Veteran's cirrhosis, which was related to his chronic liver disease was "nonalcoholic and non-viral." That notwithstanding, records dated in 2009, around the time of his initial diagnosis indicate that the Veteran's cirrhosis is "hepatic." These VA records also indicate that the Veteran worked in a chemical facility pesticides, after service. See June 14, 2018 VA primary care note. More recent VA examinations from February 2020 and February 2021 found no medical evidence support a nexus between the chronic liver disease and exposure to environmental contaminants associated with Southwest Asia Service. However, these examinations did not address whether the chronic liver disease was a diagnosable but MUCMI of inconclusive pathophysiology or etiology. Importantly, a VA examiner is not prohibited from professing whether a certain medical disease constitutes a MUCMI. Goodman v. Shulkin, 870 F.3d 1383, 1387 (Fed. Cir. 2017). Nonetheless, the VA adjudicator must make the final determination regarding whether a veteran has proven, based on the veteran's unique symptoms, the existence of a MUCMI. Id. at 1388. Given the above, as the issue of whether the Veteran's chronic liver disease is a MUCMI of inconclusive pathophysiology or etiology is unclear, remand is warranted for an addendum opinion for the Veteran's chronic liver disease. In remanding this matter, no finding is made, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. The matters are REMANDED for the following action: 1. Obtain a VA addendum opinion regarding the likely etiology of the Veteran's chronic liver disease. The claims file, including a copy of this remand, must be made available to the examiner, and the examiner must indicate that the claims file was reviewed. A complete rationale must be provided for all opinions, including answers to the questions below. The addendum opinion should address the Veteran's individual etiology and pathophysiology for purposes of determining whether the Veteran's chronic liver disease is a medically explained diagnosed illness/disability. In doing so, the examiner should address the following: 2. Is the etiology of the Veteran's chronic liver disease not understood, partially understood, or completely understood? 3. Is the pathophysiology of the Veteran's chronic liver disease not understood, partially understood, or completely understood? For the purposes of this opinion, the examiner is advised that "pathophysiology" is defined as "the physiology of abnormal states; spec[ifically]: the functional changes that accompany a particular syndrome or disease." Webster's Third New International Dictionary of the English Language Unabridged 1655 (1966). Stewart v. Wilkie, 30 Vet. App. 383, 389-90, n.5 (2018). Furthermore, the examiner is advised that "etiology" is defined as "all of the factors that contribute to the occurrence of a disease or abnormal condition." Id. If either etiology or pathophysiology is only partially understood, or not understood at all, then is the diagnosed illness characterized by overlapping signs and symptoms with features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities? If the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. In this regard, the regulations indicate that chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis will not be considered medically unexplained. In rendering these opinions, the examiner is advised that discussing general risk factors for chronic liver disease does not qualify as conclusive etiology or pathophysiology as it pertains to the Veteran's individual disability. (Continued on the next page) In providing the requested opinion, the clinician should consider the Veteran's reported in-service exposure to environmental contaminants and symptoms in service and thereafter, including the nature of his reported injury and the onset, progression and severity of his reported symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported exposure and symptoms in service and thereafter represented the onset of his current disabilities, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Small, Attorney Advisor 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.