Citation Nr: 21010333 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 17-51 594 DATE: February 24, 2021 ORDER A compensable rating for scar, healed infected cyst, left thigh prior to August 8, 2019, is denied. A 10 percent rating, but no higher, for scar, healed infected cyst, left thigh is granted effective August 8, 2019. Service connection for pituitary microadenoma, claimed as brain lesions due to spider bite, is denied. FINDINGS OF FACT 1. Prior to August 8, 2019, the Veteran’s scar, healed infected cyst, left thigh, was neither painful nor unstable. The area of the scar was less than 12 square inches or 77 square centimeters. 2. From August 8, 2019, the Veteran’s scar, healed infected cyst, left thigh, was painful. The area of the scar was less than 12 square inches or 77 square centimeters. 3. The preponderance of the evidence is against finding that pituitary microadenoma, claimed as brain lesions, began during active service or is otherwise related to an in-service injury or disease, to include a spider bite. CONCLUSIONS OF LAW 1. The criteria for a compensable disability rating for scar, healed infected cyst, left thigh have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7801. 2. From August 8, 2019, the criteria for a disability rating in excess of 10 percent for scar, healed infected cyst, left thigh have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7804. 3. The criteria for service connection for pituitary microadenoma, claimed as brain lesions due to spider bite, are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from July 1980 to July 1986. These issues were previously before the Board. In November 2019, the Board remanded the appeal to the agency of original jurisdiction (AOJ) for additional development. Specifically, the Board directed the AOJ to obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran’s left thigh spasms and to schedule the Veteran for an examination to determine the nature and etiology of his current brain lesions. An addendum opinion for the Veteran’s left thigh scar was obtained in February 2020 and the Veteran underwent a VA examination in February 2020 for his claim of service connection for brain lesion. Thus, the Board finds that the AOJ substantially complied with the remand directives and no further action is necessary in this regard. Stegall v. West, 11 Vet. App. 268 (1998). Following evidentiary development, the VA Appeals Management Center (AMC) continued the previous denials in a supplemental statement of the case (SSOC) issued in August 2020. A corresponding rating decision, however, granted a separate rating for “painful” left thigh scar, with an evaluation of 10 percent effective January 19, 2020, effectively granting a compensable rating for the Veteran’s “residual” scar. Put another way, the claim on appeal with regards to an increased rating for the Veteran’s “residual” scar on his left thigh can be characterized as a claim for a compensable rating for left thigh scar prior to January 19, 2020, and for a rating greater than 10 percent from January 19, 2020. In a September 2020 rating decision, the Veteran was granted a separate rating of 10 percent for left thigh muscle spasm effective July 29, 2016. The Board observes that the Veteran may be conflating the claim of service connection for brain lesions and the claim of service connection for trigeminal neuralgia as he claimed that both stemmed from the same spider bite during service. The claim of service connection for trigeminal neuralgia was denied in a June 2019 rating decision, and is separate and distinct from the claim of service connection for brain lesions currently before the Board. The Veteran did not submit a Notice of Disagreement (NOD) in response to the June 2019 rating decision. 1. A compensable rating for scar, healed infected cyst, left thigh prior to August 8, 2019 and for a rating greater than 10 percent from August 8, 2019. The Veteran contends that his residual scar causes pain and spasms, warranting a compensable rating. As discussed above, the Veteran’s left thigh scar is rated under 38 C.F.R. § 4.118, Diagnostic Code 7801 prior to January 19, 2020, and under Diagnostic Code 7804 from January 19, 2020. He is also in receipt of a separate rating under 38 C.F.R. § 4.73, Diagnostic Code 5314 for left thigh muscle spasms associated with his service-connected left thigh scar from July 29, 2016. Factual Background Service connection was granted for the Veteran’s residual scar in a November 2016 rating decision, effective July 29, 2016. The effective date was the date the AOJ received the Veteran’s claim. The Veteran’s scar measured 0.9 square inches, deep nonlinear, and was neither painful nor unstable. In the October 2016 VA examination, the Veteran did not report pain but reported that he had intermittent spasms lasting approximately 1 to 2 minutes. In a VA Form 9 submitted in October 2017, the Veteran did not disagree with the October 2016 VA examiner’s statement that the scar was neither painful nor unstable. He reiterated, however, that he experienced spasmic episodes with “moderate electrical sensation.” In June 2019, during a VA examination, the Veteran again reported that the scars were not painful or unstable. On August 8, 2019, the Veteran testified that his scar became shorter over time and testified that he had different degrees of pain lasting 20 seconds to 90 seconds at a time. On January 19, 2020, during a VA examination, the Veteran reported that he had “irritating type pain” in his scar. The scar was not unstable. In an August 2020 rating decision, the AOJ granted service connection for painful residual scar, healed infected cyst, left thigh with an evaluation of 10 percent effective January 19, 2020. The effective date was based on the Veteran’s report of pain during the January 2020 VA examination. A rating greater than 20 percent was denied as the single service-connected scar was not both painful and unstable. In a September 2020 rating decision, the AOJ granted service connection for left thigh muscle spasm with an evaluation of 10 percent effective July 29, 2016. A higher rating of 30 percent was not warranted as there was no evidence showing functional loss rated as moderately severe. Analysis—prior to August 8, 2019 Applying the criteria set forth above to the facts in this case, the Board finds that the preponderance of the evidence is against the assignment of a compensable rating prior to August 8, 2019. Under 38 C.F.R. § 4.118, Diagnostic Code 7801, a compensable rating requires the area of the scar to cover an area of at least 6 square inches or 39 square centimeters. The Veteran’s “residual” scar was measured to be no greater than 0.9 square inches or 5.94 square centimeters, which is smaller than the area required for a 20 percent rating. The Veteran also testified that his scar became smaller over time, rather than larger. Under 38 C.F.R. § 4.118, Diagnostic Code 7804, a compensable rating requires one or two scars that are unstable or painful. There is no medical evidence or lay statements of record reporting pain or instability of the scar prior to August 8, 2019. There is also no medical evidence or lay statements of record suggesting that the Veteran’s scar may warrant a separate rating under a different diagnostic code, or a greater rating based on the scar becoming larger. Diagnostic Codes 7800-7805 were revised, effective August 13, 2018. These new regulations apply to claims that were pending on August 13, 2018 (such as here), if the new regulations are more favorable to the Veteran's case. Diagnostic Code 7804, however, was unaffected by the revision of the rating criteria effective August 13, 2018. The Board notes that the Veteran has been assigned a separate rating for spasms associated with his left thigh scar effective July 29, 2016 the same date he was granted service-connection for left thigh scar. The Veteran did not report any other symptoms pertaining to the scar other than those relating to the claim of service connection for brain lesions that will be discussed below. For the foregoing reasons, the preponderance of the evidence reflects that the criteria for a compensable rating for the Veteran’s residual scar, healed infected cyst, left thigh, have not been met or more nearly approximated prior to August 8, 2019. The benefit-of-the-doubt-doctrine is therefore not for application and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Analysis—from August 8, 2019 During the hearing on August 8, 2019, the Veteran reported that his scar was painful for the first time. Affording him the benefit of the doubt, a 10 percent rating is warranted from this date, prior to his January 2020 VA examination. The Veteran’s testimony describing some pain in the region of the scar is broadly construed to equate to painful scarring which warrants a 10 percent rating under Diagnostic Code 7804. The evidence, however, does not warrant a grant of a 10 percent rating prior to August 8, 2019 as there is no evidence of the left thigh scar being painful prior to then, as discussed in detail above. There is also no evidence of other symptoms or changes that would warrant separate ratings under different diagnostic codes. Thus, the criteria for a compensable rating are not met prior to August 8, 2019. In sum, the evidence supports a 10 percent rating for “painful” scar as of August 8, 2019 but does not support a 10 percent rating prior to that date or a rating in excess of 10 percent from August 8, 2019. As the preponderance of the evidence is against assignment of any higher rating, the benefit-of-the doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 2. Service connection for pituitary microadenoma, claimed as brain lesions due to spider bite The Veteran contends that his brain lesions were caused by a spider bite during service. Factual Background In August 2016, the Veteran submitted medical literature that listed “infections, injuries, chemical exposure and immune system deficiencies” as possible causes of brain lesions while stating that the specific cause of a brain lesion’s appearance was usually unknown. Another medical literature stated that spider venoms were “famous for causing dermonecrotic lesions in human tissues” but did not discuss brain lesions. A literature on brown spiders stated that a bite caused dermonecrosis at the bite site which may lead to “acute renal failure, and coagulant activity.” Again, there was no discussion of brain lesions. In November 2016, the AOJ denied the Veteran’s claim as there was no evidence of a currently diagnosed disability. Private medical records associated with the Veteran’s file in October 2017 show that the Veteran had “multiple regions of abnormal T2 signal in the subcortical white matter” after a motor vehicle accident with head trauma in September 2008. The private practitioner commented that “the possibility of vasculitis needs to be considered in the differential diagnosis in view of the patient’s age and the distribution of lesions,” and that the “possibility of demyelinating disease is to be considered given the number of lesions.” The practitioner added, however, that “the relative absence of more periventricular involvement or posterior fossa brainstem involvement makes [the possibility of demyelinating disease] less likely.” In December 2008, the Veteran underwent workup for demyelinating disorder. There was a delayed response involving the right optic nerve. A September 2011 brain MRI found stable subcortical white matter disease compared to September 2008 and found no abnormality in the trigeminal ganglia region. In May 2015, the Veteran had white matter changes and signs that may or may not be “subclinical MS.” The practitioner noted that the Veteran’s complaints began after his involvement in a motor vehicle accident and that the white matter changes were first noted then. The Veteran had not complained of neurological deficits other than some paresthesias. In January 2017, an MRI examination showed that the Veteran had moderate supratentorial white matter disease that likely represented moderate chronic microvascular ischemic changes. In July 2017, a private practitioner stated that the Veteran has “hemicrania cephalgia vs. trigeminal neuralgia vs. a form of cluster headache.” In an October 2017 VA Form 9, the Veteran contended that the submitted medical literature showed a connection between his spider bite in service and his brain lesions. In January 2019, an MRI of the brain showed probable pituitary microadenoma. The Veteran’s white matter were most consistent with small vessel ischemic change. There was no other diagnosis related the Veteran’s brain. Treatment records from February 2019 state that the Veteran’s pituitary tumor was diagnosed by scan and that it was associated by left headache. In March 2019, the Veteran submitted medical literature titled “Trigeminal Autonomic Cephalgias (TACs) Due to Structural Lesions” that found TACs can be caused by an underlying lesion. The article further stated, however, that the pathophysiologic mechanism of TACs were largely unknown, and none of the cases studied in the article cited spider bites as the cause of either structural lesions or TACs. The article discussed a “remarkably high number of patients” who had pituitary tumor, but again did not comment on the possible cause of the tumor. In April 2019, the Veteran submitted medical records showing that he was diagnosed as having trigeminal neuralgia in September 2011. The records did not discuss the relationship between spider bites and brain lesions. In June 2019, the Veteran submitted additional private medical treatment records, showing a diagnosis of pituitary microadenoma in January 2019. The private practitioner remarked that there were changes of advancing chronologic age. In an August 2019 hearing, the Veteran testified that he believed there to be a “tie-in with the brain lesions and trigeminal neuralgia.” The Veteran testified that he had been “dealing with this since 2009.” He also contended that it was the spider venom in his blood stream that caused brain lesions and that he endured “eye pain, headaches” before the lesions showed up on his MRI. In January 2020, a VA examiner opined that the Veteran’s brain lesion was less likely than not incurred in or caused by the Veteran’s service. The examiner opined that the Veteran’s medical records did not support that any currently diagnosed condition was related to the spider bite during service. The examiner noted that the Veteran was diagnosed as having pituitary microadenoma and that there was nothing in the medical record to connect these two separate issues chronologically. The examiner also opined that there was nothing in the medical literature that support white matter changes and/or pituitary adenoma to a spider bite. In August 2020, the AOJ issued a Supplemental Statement of the Case (SSOC) continuing the denial of the claim of service connection for brain lesion. The AOJ found that the current diagnosis was that of pituitary microadenoma, that the disability occurred after discharge, and that the examiner found that the disability was not connected to the Veteran’s service, to include a spider bite. In August 2020, the Veteran submitted a copy of the article titled “Trigeminal Autonomic Cephalgias Due to Structural Lesions” he had submitted in March 2019, and submitted a statement explaining his argument regarding trigeminal neuralgia. Analysis After considering the evidence of record, the Board concludes that the most probative evidence establishes that the Veteran’s current pituitary microadenoma is not causally related to his active service or any incident therein, to include spider bite during service. Service connection may be granted for a disability resulting from personal injury suffered or disease contracted in the line of duty. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may also be granted for a 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). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 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. Id.; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). “It is in recognition of our debt to our veterans that society has [determined that,] [b]y tradition and by statute, the benefit of the doubt belongs to the veteran.” Gilbert, 1 Vet. App. at 54. As an initial matter, the Board finds that the Veteran is currently diagnosed as having pituitary microadenoma. The most recent MRI by a private practitioner in January 2019 resulted in no other diagnosis, and the private practitioner also associated the Veteran’s headaches with the pituitary microadenoma (tumor). There is no medical opinion of record that connects the Veteran’s pituitary microadenoma to spider bite during service. The February 2020 VA examiner opined that there was no medical literature showing a causal relationship between spider bite and pituitary microadenoma that was found decades after the spider bite during service. There is also no medical opinion of record that connects the Veteran’s brain lesions to the spider bite. As discussed above, private medical opinions associate the Veteran’s lesions and white matter disease to his motor vehicle accident in September 2008. The Board has also reviewed the medical literature submitted by the Veteran and the Veteran’s contention that the literature supported a causal relationship between spider venom and brain lesions. Although the medical literature discusses dermanecrotic lesions, or lesions of the skin, in relation to spider venom, there is no discussion of brain lesions. Moreover, they are too generic to have any probative value. See, e.g., Mattern v. West, 12 Vet. App. 222, 228 (1999) (generic texts, which do not address the facts in this particular case with any degree of medical certainty, do not amount to competent medical evidence). They also do not suggest a causal relationship between spider venom and pituitary microadenoma, the disability that the Veteran is currently diagnosed as having. Moreover, to the extent the Veteran asserts that a relationship exists between his pituitary microadenoma or brain lesions and spider bite in service, the Board finds that such assertions do not provide persuasive evidence in support of the claim. The matter of the medical etiology of the disability here at issue is one within the province of trained medical professionals. Jones v. Brown, 7 Vet. App. 134, 137–38 (1994). Although lay persons are competent to attest to matters within their own personal knowledge, to include symptoms experienced or observed (as appropriate), as well as to provide opinions on some medical issues, such as those perceived through the senses (see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011)), here, the etiology of the Veteran’s pituitary microadenoma is a complex medical matter that falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, lay assertions as to the etiology of the Veteran’s pituitary microadenoma or brain lesions have no probative value. In summary, the absence of competent medical or scientific evidence documenting a relationship between the Veteran’s pituitary microadenoma and his spider bite, service connection on a direct basis must be denied. Therefore, the evidence in this case is not so evenly balanced as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54. The preponderance of the evidence is against the Veteran’s claim, and as such entitlement to service connection for pituitary microadenoma, claimed as brain lesions, is denied. JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board H. Yun 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.