Citation Nr: 21013619 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 16-39 218 DATE: March 10, 2021 ORDER Service connection for psoriatic arthritis, to include as due to herbicide agent exposure is denied. FINDING OF FACT 1. The Veteran had service within the Republic of Vietnam during the Vietnam Era and is presumed to have been exposed to herbicide agents. 2. Currently diagnosed psoriatic arthritis was not incurred in or caused by active service, to include as due to herbicide agent exposure. 3. Psoriatic arthritis was not both chronic in service with continuous symptoms since service separation, and did not manifest to a compensable degree within one year of service separation. CONCLUSION OF LAW The criteria for service connection for psoriatic arthritis, to include as due to herbicide agent exposure have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5103, 5103A, 5107, 5121 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.303, 3307, 3.309 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service with the U.S. Army from November 1966 to September 1968, to include service within the Republic of Vietnam. This matter comes on appeal before the Board of Veterans’ Appeals (Board) from a September 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office in Winston Salem, North Carolina (RO). The appeal was previously before the Board in November 2018, and was remanded for record development, to include a VA examination. The appeal was again before the Board in July 2020 and was again remanded for substantial compliance with prior remand directives. Stegall v. West, 11 Vet. App. 268 (1998). The Board finds that substantial compliance as been obtained and that it may proceed with further appellate adjudication at this time. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall, 11 Vet. App. 268, where the Board’s remand instructions were substantially complied with), aff’d, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). Service connection for psoriatic arthritis, to include as due to herbicide exposure Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (a) (2018). Service connection may 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) (2018). As a general matter, service connection for a disability requires evidence of (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Additionally, several alternative paths to service connection exist for certain chronic diseases identified in 38 C.F.R. § 3.309 (a), including arthritis. 38 C.F.R. § 3.309. Service connection may be awarded if a chronic disease manifests itself and is identified as such in service, or within the presumptive period under 38 C.F.R. § 3.307, and the Veteran presently has the same condition, unless the condition is clearly attributable to intercurrent causes. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309; see Walker v. Shinseki, 708 F.3d 1331, 1336 (Fed. Cir. 2013). Additionally, the continuity of symptomatology provision of 38 C.F.R. § 3.303 (b) has been interpreted as an alternative to service connection for the chronic diseases listed in 38 C.F.R. § 3.309 (a). See Walker, at 1331. A Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 U.S.C. § 1116 (f) (2012); 38 C.F.R. § 3.307 (a)(6)(iii) (2019). If the Veteran was exposed to an herbicide agent, such as Agent Orange, during active service, service connection will be presumed for certain diseases which are listed at 38 C.F.R. § 3.309 (e), if the requirements of 38 C.F.R. § 3.307 (a) are met, even if there is no record of such disease during service. Because the Veteran served in the Republic of Vietnam during the appropriate time frame, he is presumed to have been exposed to herbicide agents during his service. The Board notes that psoriatic arthritis is not one of the listed diseases for such presumption under 38 C.F.R. § 3.309 (e). The lack of a presumption, however, does not mean that the disability cannot be granted on a direct causation basis, to include if it were shown that the Veteran in this case has the disability due to exposure to Agent Orange. See Combee v. Brown, 5 Vet. App. 248 (1993). In rendering a decision on appeal, the Board must analyze the credibility and probative value of all medical and lay evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the veteran. 38 U.S.C. § 1154 (a) (2012); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). The standard of proof to be applied in decisions on claims for veterans’ benefits is set forth in 38 U.S.C. § 5107. A veteran is entitled to the benefit of the doubt when there is an approximate balance of evidence for and against the claim. See 38 C.F.R. § 3.102 (2019). When a veteran seeks benefits and the evidence is in relative equipoise, the veteran prevails. See Gilbert, 1 Vet. App. 49. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Service treatment records do not show complaints, treatment or diagnosis of a rash, psoriasis or arthritis. A September 1968 separation examination shows a normal clinical evaluation of the skin, and an abnormal musculoskeletal examination due to loss of motion of the left index finger. Military personnel records include a DD-214, which shows the Veteran was awarded the Vietnam Service Medal and Vietnam Campaign Medal. Private treatment records from April 2012 and September 2013 show the Veteran sought treatment for psoriatic arthritis, and received treatment from this facility as early as 2010. VA treatment records include a January 2014 rheumatology consult, in which the Veteran indicated he had psoriasis for the past 12 years, and was diagnosed with rheumatoid arthritis and psoriatic arthritis 5 years prior. He sought treatment with private rheumatologists up until now. He was prescribed methotrexate, Humira, Enbrel and Cimzia, all of which did not help. A March 2019 note shows that he reported having psoriasis since the late 1960s, with polyarthralgia onset in the 2000s. Imaging of the bilateral hand showed osteoarthritic changes with no mention of psoriatic arthritis or rheumatoid arthritis. The Veteran was assessed with a history of psoriasis and psoriatic arthritis which appeared adequately controlled with prescribed Enbrel. A February 2020 VA skin condition examination confirmed the Veteran’s diagnosis of psoriasis, which the Veteran reported to have began in 1985. He reported it began on his right knee, and as time went on, it progressed to his elbows, hands and fingers. Within a corresponding February 2020 VA arthritis examination, the Veteran was diagnosed with rheumatoid arthritis, psoriatic arthritis and degenerative osteoarthritis. Upon review of the Veteran’s claims file, and upon interview and examination of the Veteran, the VA examiner opined that psoriasis was less likely than not incurred in or caused by active service. The examiner indicated that they were unable to find medical literature to support psoriasis as derived from an herbicidal exposure. The examiner also indicated that the Veteran’s skin symptoms began in the mid-1980s, with psoriatic arthritis in the early 2000s, and that service treatment records do not show any rash complaints or diagnosis of psoriasis during active duty or within a year of separation. A January 2021 VA examination also shows a diagnosis of rheumatoid arthritis. Upon review of the record, and on interview and examination of the Veteran, the VA examiner opined that psoriasis and psoriatic arthritis were less likely than not incurred in or caused by active service. The VA examiner indicated that no medical literature supports the development of psoriasis from herbicide exposure. They explained that symptoms of arthritis occurred 30 years after leaving the army. Additionally, the examiner indicated that x-ray films will not differentiate arthritic changes due to osteoarthritis vs psoriatic arthritis vs rheumatoid arthritis. As an initial matter, the Board finds that the Veteran had service within the Republic of Vietnam during the Vietnam Era and is presumed to have been exposed to herbicide agents. The Veteran’s DD-214 shows he was awarded the Vietnam Service Medal and Vietnam Campaign Medal. While the Veteran had been presumptively exposed to herbicide agents while in service, the Board finds that psoriatic arthritis was not incurred in or caused by service, to include as due to herbicide agent exposure. There is no evidence of complaints, treatment, or diagnoses of a rash or psoriatic arthritis during active service, and there is no indication of symptoms, treatment, or diagnoses for psoriatic arthritis until many decades after service separation in 2010. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is one factor to consider as evidence against a claim of service connection); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible). Further, the Board finds probative, in the aggregate, the VA examinations of record, which find that psoriatic arthritis and psoriasis were less likely than not incurred in or caused by active service, to include as due to herbicide agent exposure. The VA medical opinions of record show that there is no medical literature linking psoriasis to herbicide agent exposure. Further, the Veteran did not report having psoriasis until the mid-1980s with no reports of psoriatic arthritis until the early 2000s, almost 30 years after service separation. There are no other medical opinions of record which weigh in favor of the claim. Similarly, upon review of all the evidence, lay and medical, the Board finds that psoriatic arthritis was not both chronic in service with continuous symptoms since service separation, and did not manifest to a compensable degree within one year of service separation. As indicated above, service treatment records do not show complaints, treatment or a diagnosis of a rash, psoriasis or arthritis in service. The Board notes that medical evidence of record shows the Veteran established private treatment in 2010 related to psoriatic arthritis, with earliest evidence in April 2012 private treatment notes showing a diagnosis if psoriatic arthritis – many decades after separation in 1968. Maxson, 230 F.3d at 1333; Buchanan, 451 F.3d at 1336. And while the Veteran, within VA treatment records indicated he had psoriasis since the late 1960s, the Veteran also reported having psoriasis beginning in the mid-1980s within VA examinations of record. Insomuch as the Veteran contends that diagnosed psoriatic arthritis is related to his in-service exposure to herbicide agents, the Board finds that he is not competent to render such an opinion, as he lacks the medical training and expertise to provide a complex medical nexus opinion. Jandreau v. Nicholson, 492 F.3d 1372, (Fed. Cir. 2007). (Continued on the next page)   For the reasons discussed above, service connection for psoriatic arthritis, to include as due to herbicide agent exposure is not warranted. Because the preponderance of the evidence is against the Veteran’s claims, the benefit-of-the-doubt doctrine is not for application. See 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. R. Woodarek 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.