Citation Nr: 21016109 Decision Date: 03/19/21 Archive Date: 03/19/21 DOCKET NO. 16-15 590 DATE: March 19, 2021 ORDER Service connection for a skin disorder, claimed as lumps or tumors on the chest, is denied. FINDING OF FACT A skin disorder, to include lumps or tumors on the chest, was not manifest in service and is unrelated to service, to include exposure to herbicide agents therein. CONCLUSION OF LAW The criteria to establish service connection for a skin disorder, to include lumps or tumors on the chest, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from July 1969 to July 1971, to include service in Vietnam. This matter comes before the Board from a February 2014 rating decision by the Agency of Original Jurisdiction (AOJ). In September 2018, the Board denied the Veteran’s claim of entitlement to service connection for hypertension, and remanded issues of entitlement to service connection for lumps on the chest and peripheral neuropathy of the right lower extremity. In February 2020, the AOJ awarded service connection for peripheral neuropathy of the right lower extremity. The Board again remanded the issue of entitlement to service connection for a skin disorder in July 2020. Entitlement to VA compensation may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. §§ 1110 (wartime service), 1131 (peacetime service); 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, a Veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service”-the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). However, “[a] determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service.” Watson v. Brown, 4 Vet. App. 309, 314 (1993). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. A decision of the U.S. Court of Appeals for the Federal Circuit (Federal Circuit), however, clarified that this notion of continuity of symptomatology since service under 38 C.F.R. § 3.303(b), which as mentioned is an alternative means of establishing the required nexus or linkage between current disability and service, only applies to conditions identified as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 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. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. 38 C.F.R. § 3.307(a)(6)(iii). The U.S. Court of Appeals for the Federal Circuit recently held that “[s]ervice in the Republic of Vietnam” includes service on the landmass, inland waterways, and in the territorial sea extending 12 nautical miles from the shores of that nation. Procopio v. Wilkie, 913 F.3d 1371 (Fed. Cir. 2019). VA regulations provide for presumptive service connection for specific diseases associated with exposure to herbicide agents. Those diseases that are listed at 38 C.F.R. § 3.309(e) shall be presumptively service-connected if there are circumstances establishing herbicide agent exposure during active military service, even though there is no record of such disease during service. Lipomas, such as those diagnosed in the Veteran, are not listed at 38 C.F.R. § 3.309(e); however, the provisions for presumptive service connection do not preclude a claimant from establishing service connection with proof of actual direct causation, on the basis that his exposure to herbicides led to the development of the claimed disability after service. See Combee v. Brown, 34 F.3d 1039, 1044 (Fed. Cir. 1994). The Veteran asserts that he has had recurring lumps on his chest that are related to service, to include exposure to herbicide agents therein. Service treatment records are negative for any diagnosis, complaint, or abnormal finding suggesting a skin disorder of the chest, to include lumps or tumors. The Veteran was seen by a private provider in October 2003, reporting a lump on his chest. Examination revealed two moveable nodules. The provider indicated questionable sebaceous cysts. Mammogram in November 2003 revealed no stromal tissue, ductal tissue, mass, architectural distortion, or abnormal calcification. The impression was normal mammogram bilaterally and normal ultrasound bilaterally. The Veteran underwent excision of a soft tissue mass from his left chest wall in November 2007. The final diagnosis was lipoma. On VA examination in January 2021, the diagnoses were benign breast mass and actinic keratosis on the scalp. The examiner acknowledged that the Veteran had been exposed to herbicides. The Veteran reported a history of breast masses, with current cystic masses bilaterally. He indicated that previous mammogram was negative. The examiner concluded that neither skin disorder was related to service. Regarding the lipomas, she indicated that such was a benign condition not associated with herbicides. She noted that lipomas presented as soft, painless subcutaneous nodules that ranged in size. She indicated that they occurred most frequently on the trunk and upper extremities and could vary in shape. She noted that frequently, individuals might have more than one lipoma, and that they also might result from a genetic condition. She acknowledged that soft tissue sarcomas were associated with Agent Orange exposure, but that the Veteran had not been diagnosed with soft tissue sarcoma. The Board concludes that, while the Veteran has been diagnosed with lipomas of the chest wall, the preponderance of the evidence weighs against finding that the Veteran’s lipomas began during service or is otherwise related to an in-service injury, event, or disease. The record demonstrates that lipomas were first treated in 2003, many years following service. The record demonstrates that lipomas are not related to service, to include exposure to herbicide agents therein. To the extent that the Veteran asserts that his lipomas are related to service, the Board observes that he may attest to factual matters of which he has first-hand knowledge, such as subjective complaints, and that his assertions in that regard are entitled to some probative weight. He is competent to report incidents and symptoms in service and symptoms since then. He is not, however, competent to render an opinion as to the cause or etiology of the current diagnosis because he does not have the requisite medical knowledge or training, and because this matter is beyond the ability of a lay person to observe. As discussed, the VA examiner considered the Veteran’s documented history, but ultimately concluded that the Veteran’s lipomas are not related to service, to include his presumed exposure to Agent Orange. The Board finds the most probative evidence of record to be this opinion by the competent VA health care provider. In assigning high probative value to the VA examiner’s opinion, the Board notes that she had the claims file for review, specifically discussed evidence contained in the claims file, obtained a history from the Veteran, and conducted a complete examination. There is no indication that the VA examiner was not fully aware of the Veteran’s past history or that she misstated any relevant fact. The Board thus finds the VA examiner’s opinion to be of greater probative value than the Veteran’s unsupported statements. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion); Neives-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The grant of service connection requires competent evidence to establish a diagnosis and, as in this case, relate the diagnosis to the Veteran’s service. While the record demonstrates diagnoses of lipomas, it does not contain reliable evidence which relates this claimed disability to any incident of service. (Continued on the next page)   For these reasons, the Board concludes that the claim of entitlement to service connection for a skin must be denied, as the preponderance of the evidence is against the claim. The doctrine of reasonable doubt is not applicable in the instant appeal. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Barone, 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.