Citation Nr: 21022512 Decision Date: 04/16/21 Archive Date: 04/16/21 DOCKET NO. 17-63 601 DATE: April 16, 2021 ORDER Service connection for gastroesophageal reflux disease (also claimed as gastric/stomach problems) is denied. Service connection for ingrown hairs is denied. FINDINGS OF FACT 1. The Veteran’s gastroesophageal reflux disease (also claimed as gastric/stomach problems) is not secondary to service-connected residuals of fracture, tibia/fibula status post ORIF with residual scar and is not otherwise related to service. 2. The preponderance of the evidence is against finding that the Veteran’s pseudofolliculitis barbae began during active service or is otherwise related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for gastroesophageal reflux disease (also claimed as gastric/stomach problems) have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317. 2. The criteria for service connection for ingrown hairs have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1988 to July 1991 for which he received an honorable discharge. He had additional Reserve service from July 1991 to February 2004 for which he received an other than honorable (OTH) discharge. This matter comes before the Board of Veterans’ Appeals (Board) from a September 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In October 2019, the Veteran testified before the undersigned Veterans Law Judge at a travel Board hearing. A transcript is of record. The Board remanded the issues on appeal in February 2020 for further development. There has been substantial compliance with the remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). In the February 2020 decision, the Board also denied entitlement to service connection for a disability related to numbness, left lower extremity (claimed as left leg, ankles, and toes). The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In a March 2021 Order, the Court granted a Joint Motion for Partial Remand (JMPR) by the Veteran and VA General Counsel, to vacate the Board’s decision, to the extent that it denied service connection for a disability related to numbness, left lower extremity, and remand the matter for readjudication in accordance with the JMR. The Veteran was informed in March 2021 correspondence that his appeal had been returned to the Board, and that he had 90 days to submit additional evidence. As this period has not yet expired, those issues will be the subject of a later Board decision. Service Connection Service connection may be granted for a Persian Gulf veteran with objective indications of a qualifying chronic disability that manifested either during active service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117(a)(1); 38 C.F.R. § 3.317(a)(1). A qualifying chronic disability is a chronic disability that may result from an undiagnosed illness or a medically unexplained chronic multisymptom illness (MUCMI). 38 C.F.R. § 3.317(a)(2)(i). The term MUCMI refers to a diagnosed illness without conclusive pathophysiology or etiology, 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. 38 C.F.R. § 3.317(a)(2)(ii). A multisymptom illness is a MUCMI where either the etiology or pathophysiology of the illness is inconclusive. Stewart v. Wilkie, 30 Vet. App. 383, 389-90 (2018). A multisymptom illness is not a MUCMI where both the etiology and the pathophysiology of the illness are partially understood. Id. The determination of whether a MUCMI is “medically unexplained,” that is, the etiology and pathophysiology of the multisymptom illness, must be particular to the claimant’s case. Id. at 291. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. 1. Service connection for gastroesophageal reflux disease (also claimed as gastric/stomach problems) is denied. The Veteran seeks service connection for gastroesophageal reflux disease (GERD), claimed as gastric/stomach problems. The Veteran contends his gastric/stomach problems are secondary to his service in Southwest Asia or, alternatively, secondary to his service-connected residuals of fracture, tibia/fibula status post ORIF with residual scar disability or the medications to treat his service-connected condition. For the following reasons, the Board finds service connection is not warranted. A March 2020 VA examination shows the Veteran has a diagnosis of GERD. As the Veteran’s GERD is a diagnosed condition, it cannot be considered an undiagnosed illness. 38 C.F.R. § 3.317(a)(1)(ii). Moreover, GERD is a structural gastrointestinal disorder and therefore not considered a MUCMI. 38 C.F.R. § 3.317(a)(2)(i)(B)(3); 76 Fed. Reg. 41,696 (Jul. 15, 2011); see Atencio v. O’Rourke, 30 Vet. App. 74, 83 (2018). Thus, presumptive service connection for GERD under § 3.317 is not warranted. The provisions for presumptive service connection do not preclude a claimant from establishing service connection with proof of actual direct causation or secondary causation. The Veteran’s April 1988 enlistment and June 1991 separation examinations during his period of active duty reflect normal clinical evaluations of the abdomen and viscera. A January 1989 service treatment record notes gastroenteritis, but the service records are otherwise silent for complaints of, treatment for, or a diagnosis of GERD or other chronic gastrointestinal disorder. Reserve service treatment records, including a May 2000 enlistment examination and March 2002 retention examination also reflect a normal clinical evaluation of the abdomen and viscera. No chronic gastrointestinal disorders are noted in these records. The Veteran’s May 2000 enlistment and March 2002 reports of medical history indicates he denied a history of stomach, liver, or intestinal trouble and frequent indigestion. Post-service VA and private medical records show complaints and diagnoses related to gastrointestinal disorder beginning in December 2007. These diagnoses included moderate helicobacter pylori chronic active gastritis, mild active esophagitis, consistent with GERD, and GERD. The Veteran underwent a VA esophageal conditions examination in July 2013 wherein the examiner diagnosed GERD. The Veteran also underwent a VA stomach and duodenal conditions examination wherein the examiner noted a diagnosis of status post gastric surgery. During the examinations, the Veteran stated the conditions began in 1990 and manifested with pain in his stomach, nausea, and vomiting. The examiner opined that the Veteran’s ulcer, stomach condition, and gastric condition were less likely than not incurred in or caused by service. The examiner noted there is only one pertinent service treatment record, which states gastroenteritis. The examiner indicated gastroenteritis is a self-limiting phenomenon, which indicated the condition was acute and transitory. Therefore, considering the acute and transitory in-service event, temporal relationships, and normal subsequent military exams, the examiner found it is less than likely that the claimed conditions are service-connected. An August 2016 VA treatment record shows the Veteran underwent a partial gastrectomy in 2013 secondary to duodenal ulcers and obstruction. His prior medical history was noted to be significant for peptic ulcer disease with duodenal obstruction requiring a partial gastrectomy likely attributed to nonsteroidal anti-inflammatory drugs (NSAIDs). A September 2016 VA treatment record notes evidence of grade I esophagitis, partial gastrectomy, pyloroplasty, antrectomy, and duodenitis. The Veteran underwent a VA stomach and duodenal conditions examination in July 2017. The examiner noted diagnoses of status post partial gastrectomy, pyloroplasty, antrectomy, and bilroth I anastomosis in the stomach and duodenitis of the duodenum. The examiner noted the Veteran had claimed a disability pattern related to gastric/stomach problems and service in Southwest Asia. The examiner noted the Veteran had a duodenal ulcer many years after service, with subsequent surgery, and continues to have GERD symptoms. The examiner indicated the Veteran’s disability pattern is a disease with a clear and specific etiology and diagnosis. The examiner indicated duodenal ulcer may arise from H Pylori bacteria or NSAID use, while GERD is caused by abnormal muscle function in the stomach that can disrupt flow. An abnormal structural problem such as hiatal hernia, obesity or pregnancy can weaken the lower esophageal sphincter muscles leading to reflux disorder. The examiner indicated medical literature does not support an etiological link between gastric/stomach problems (ulcer or GERD) and service in Southwest Asia such that his claimed disorders are less likely as not related to a specific exposure experienced during service in Southwest Asia. In a February 2020 remand, the Board indicated the VA opinions of record were inadequate as they related to the theory of secondary service connection. The Board noted that an August 2016VA treatment record indicates the Veteran’s history of peptic ulcer disease with duodenal obstruction and partial gastrectomy was likely attributed to nonsteroidal anti-inflammatory drugs (NSAIDs). A December 2011VA treatment record indicates NSAID use related to his service-connected lower leg disabilities. In compliance with the Board’s remand directives, an addendum opinion was obtained in March 2020. During the examination, the Veteran reported onset of symptoms in 1989 with reflux, heart burn, regurgitation, and abdominal discomfort. The examiner opined that the Veteran’s gastric/stomach problems were not at least as likely as not proximately due to or aggravated beyond its natural progression by his service-connected residuals of fracture, tibia/fibula status post ORIF with residual scar disability or the medications to treat his service-connected condition. The examiner noted there are no medications on record that the Veteran is taking on a long-term basis that are associated with or contribute to his gastric/stomach problems. Finally, the examination indicated that there is no pathophysiological relationship between the two conditions or any medical records showing such relationship and no medical physiology to explain a relationship between his fracture disability and his gastric/stomach condition. After a review of the evidentiary record, the Board finds the preponderance of the evidence weighs against entitlement to service connection for a gastric/stomach condition, including GERD. The Board concludes that, while the Veteran has a current diagnosis of GERD, and evidence shows a January 1989 assessment of gastroenteritis and service in Southwest Asia, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of GERD began during service or is otherwise related to an in-service injury, event, or disease. VA and private treatment records show the Veteran was not diagnosed with a chronic gastrointestinal condition until December 2007, years after his separation from service. While the Veteran is competent to report having experienced symptoms of stomach pain, nausea, and vomiting since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of GERD. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Further, the July 2013, July 2017, and March 2020 VA examiners opined that the Veteran’s gastric/stomach condition is not at least as likely as not related to service, including a specific in-service exposure event, his January 1989 in-service acute episode of gastroenteritis, or his service-connected residuals of fracture, tibia/fibula status post ORIF with residual scar disability. The examiners’ opinions are probative, because they are based on an accurate medical history and provide explanations that contain clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). While an August 2016 VA treatment record notes his peptic ulcer disease with duodenal obstruction was likely attributed to NSAIDs and the record suggest use of NSAIDs related to his service-connected fracture residuals, the Board notes the treatment record does not reflect consideration of the entirety of the Veteran’s medical history such that the Board finds the probative value of the treatment record is outweighed by the March 2020 VA opinion. Similarly, to the extent the Veteran contends anxiety and depression after an in-service assault caused him to have stomach ulcers, the Board finds the Veteran’s statements regarding onset not credible as they are internally inconsistent. The Veteran has alternatively reported onset of his stomach condition in 1989 (prior to the assault) and after an assault in 2001. Therefore, the Board finds the low standard of McLendon has not been met and a VA opinion is not warranted. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see also Waters v. Shinseki, 601 F.3d 1274, 1278 (2010) (a mere conclusory generalized lay statement that service caused the claimant’s current condition is insufficient to require the Secretary to provide an examination). The Veteran believes his gastric/stomach condition, including GERD, is related to an in-service injury, event, or disease. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge about the interaction between multiple organ systems in the body, pathology, and interpretation of complicated diagnostic medical testing. The record does not show this Veteran has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the claim, the doctrine is not applicable. Accordingly, service connection for GERD (claimed as gastric/stomach problems) is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). 2. Service connection for ingrown hairs is denied. The Veteran seeks service connection for ingrown hairs or pseudofolliculitis barbae. He contends his pseudofolliculitis barbae is related to his in-service tinea pedis and tinea cruris. Alternatively, the Veteran asserts his skin condition is related to service in Southwest Asia. For the following reasons, the Board finds service connection is not warranted. The Veteran is considered a Persian Gulf veteran. 38 C.F.R. § 3.317(e). A March 2020 VA examination report shows the Veteran has a diagnosis of pseudofolliculitis barbae. As the Veteran’s pseudofolliculitis barbae is a diagnosed condition, it cannot be considered an undiagnosed illness, but it is eligible for consideration as a MUCMI. 38 C.F.R. § 3.317(a)(1)(ii), (a)(2)(ii). A July 2017 VA examination report shows a VA examiner determined the Veteran’s pseudofolliculitis barbae has a fully understood etiology and a fully understood pathophysiology. With respect to the etiology and pathophysiology of the Veteran’s pseudofolliculitis barbae, the clinician explained pseudofolliculitis barbae is a diagnosable condition with a clear etiology as a type of folliculitis. Also known as folliculitis barbae, shaving rash, or razor bumps; it is a foreign-body inflammatory reaction surrounding ingrown facial hair, which results from shaving. The examiner indicated pseudofolliculitis barbae occurs more commonly in people who have curly hair, because the curl of the hair means that sharp pointed end of a recently shaved hair comes out from the skin and reenters the skin close by. Finally, the examiner noted medical literature does not support an etiological link between pseudofolliculitis barbae and service in Southwest Asia. The Board finds this opinion probative because the opinion was provided by a medical professional who possesses the necessary education, training, and expertise to provide the requested opinion. Additionally, the opinion is also shown to have been based on a review of the Veteran’s record and is accompanied by a sufficient explanation as to why the Veteran’s pseudofolliculitis barbae is not a MUCMI. Accordingly, as both the etiology and the pathophysiology of the Veteran’s pseudofolliculitis barbae are fully understood, it is not considered a MUCMI and presumptive service connection is not warranted. The provisions for presumptive service connection do not preclude a claimant from establishing service connection with proof of actual direct causation. The Veteran’s April 1988 enlistment during his period of active duty reflects normal clinical evaluation of the skin and lymphatics. A July 1989 service treatment record notes a leg rash assessed as tinea cruris. A November 1989 service treatment record notes foot pain assessed as tinea pedis. A December 1989 service treatment record notes complaints of recurrent tinea pedis. The Veteran’s service treatment records are otherwise silent for complaints of, treatment for, or a diagnosis related to pseudofolliculitis barbae. The June 1991 separation examination reflects a normal clinical evaluation of the skin and lymphatics. Reserve service treatment records, including a May 2000 enlistment examination and March 2002 retention examination also reflect a normal clinical evaluation of the skin and lymphatics. The Veteran’s reports of medical history, completed in May 2000 at enlistment and in March 2002 at separation, indicates the Veteran denied a history of skin diseases. A February 2009 post-service private treatment record notes his skin color was normal without rash. VA treatment records dated in December 2011, April 2012, and April 2013show diagnoses of tinea barbae. The Veteran underwent a VA skin examination in July 2013. During the examination, the Veteran reported a history of ingrown hairs since 2005. He indicated it happened over time after shaving. The examiner noted the Veteran did not have a skin condition. The examiner noted there is no diagnosis because there is no pathology to render a diagnosis. The examiner opined that the condition was less likely than not incurred in or caused by service as there is no current diagnosis. VA treatment records dated in March 2014, June 2016 and June 2017show tinea barbae. A July 2017 VA skin examination reflects a diagnosis of pseudofolliculitis barbae. During the examination, the Veteran reported ingrown hairs since service on the face and neck. The examiner noted the Veteran exhibits mild folliculitis of his beard area to include a few comedones and papules of his cheeks and anterior neck; however, the shaved area of head and back of neck remain clear. The examiner found the Veteran’s skin condition was less likely than not related to an environmental exposure experienced in the Gulf War. An August 2017 VA treatment record notes tinea barbae and tinea capitis. In compliance with the Board’s prior remand directives, an addendum opinion was obtained in March 2020. The examiner noted a current diagnosis of pseudofolliculitis barbae. The examiner opined that the Veteran’s pseudofolliculitis barbae was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. After reviewing all medical record, the Board’s remand, and performing a physical examination, the examiner found the Veteran’s pseudofolliculitis barbae is less likely than not proximately due to or the result of tinea pedis and tinea cruris. The examiner explained there is no pathophysiological relationship between the conditions (i.e. the tinea pedis on the feet and tinea cruris on the leg shown during active duty and the current pseudofolliculitis barbae) or any medical records showing such relationship. Finally, the examiner noted there is no direct correlation between tinea pedis and tinea cruris causing or inducing pseudofolliculitis barbae as there is no medical physiology to explain such a relationship. After a review of the evidentiary record, the Board finds the preponderance of the evidence weighs against entitlement to service connection for pseudofolliculitis barbae. The Board concludes that, while the Veteran has a current diagnosis of pseudofolliculitis barbae, and the evidence shows in-service findings of tinea pedis and tinea cruris, as well as service in Southwest Asia, the preponderance of the evidence weighs against finding that the Veteran’s pseudofolliculitis barbae began during service or is otherwise related to an in-service injury, event, or disease. VA and private treatment records show the Veteran has alternatively reported onset of ingrown hairs since 2005 and onset during service. His statements regarding onset are not credible as they are internally inconsistent and also inconsistent with his contemporaneous treatment records. The Board reiterates that the Veteran’s service treatment records are silent for a diagnosis of pseudofolliculitis barbae or complaint of ingrown hairs. Thus, while the Veteran is competent to report having experienced certain symptoms since service, the Board finds such reports to be not credible and worth little probative value. Similarly, to the extent that the Veteran asserts a nexus to active service and he is competent to report symptoms affecting his skin both in service and after service, he is not competent to diagnose pseudofolliculitis barbae and distinguish this condition from other chronic skin diseases. Further, the July 2017, and March 2020 VA examiners opined that the Veteran’s pseudofolliculitis barbae is not at least as likely as not related to service, including a specific in-service exposure event or his in-service complaints of tinea pedis and tinea cruris. The examiners’ opinions are probative, because they are based on an accurate medical history and provide explanations that contain clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Moreover, the Board notes there is not a competent opinion establishing a nexus to service of record. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the claim, the doctrine is not applicable. Accordingly, service connection for pseudofolliculitis barbae is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55-57. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.Aoughsten, Associate 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.