Citation Nr: 21022812 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 16-46 133 DATE: April 19, 2021 ORDER Entitlement to service connection for a skin disability, diagnosed as dermatitis of the bilateral upper extremities and a lipoma of the left upper arm, is granted. Entitlement to service connection for anemia is denied. Entitlement to service connection for hypothyroidism is denied. Entitlement to service connection for diabetes mellitus is denied. Entitlement to service connection for a back disability is denied. FINDINGS OF FACT 1. Resolving reasonable doubt in his favor, the Veteran’s skin disability is etiologically related to his active service. 2. The Veteran’s hypothyroidism did not manifest during active service or within one year of active service, and there is no indication that it is otherwise causally related to active service. 3. The Veteran’s anemia did not manifest during active service or within one year of active service, and there is no indication that it is otherwise causally related to active service. 4. The Veteran’s diabetes mellitus did not manifest during active service or within one year of discharge from active service, and there is no indication that it is otherwise causally related to active service. 5. The Veteran’s back disability did not manifest during active service, arthritis did not manifest within one year of discharge from active service, and there is no indication that his back disability is otherwise related to his active service. CONCLUSIONS OF LAW 1. The criteria for service connection for a skin disability are met. 38 U.S.C. §§ 1110, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2020). 2. The criteria for service connection for hypothyroidism are not met. 38 U.S.C. §§ 1101, 1110, 1112, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 3. The criteria for service connection for anemia are not met. 38 U.S.C. §§ 1101, 1110, 1112, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 4. The criteria for service connection for diabetes mellitus are not met. 38 U.S.C. §§ 1101, 1110, 1112, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 5. The criteria for service connection for a back disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the Tennessee Army National Guard from December 1972 to December 1994. He had active service from February 1973 to June 1973, and from September 1990 to July 1991. He served in the Southwest Asia theater of operations from October 1990 to June 1991. This case initially came before the Board of Veterans’ Appeals (Board) on appeal from a March 2014 rating decision issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). In June 2019, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In November 2019, the Board remanded the claims for additional development. The case has since been returned to the Board. Service Connection – Skin Disability The Veteran maintains that his skin disability was incurred in or is related to active service during the Persian Gulf War. During the June 2019 Board hearing, he stated that he began having rashes after he came back from service. He stated that he had rashes on and off involving his forearms and hands, and that it sort of healed up but that he had a lot of scarring and areas of hypopigmentation. The Veteran’s service treatment records indicated that he requested a shaving profile in July 1979. In June 1981, he reported itching and burning secondary to shaving. In April 1991, he indicated that he had a shaving disorder. His service treatment records are otherwise unremarkable for any complaints, treatment, or diagnoses related to the skin. At an April 1992 periodic examination, he denied having skin diseases. Post service, a March 2006 VA treatment record noted that the Veteran had a dry, hyperpigmented, scaly rash of the extensor surface of the right elbow. The diagnosis was psoriasis. In July 2011, it was noted that he also had skin tags. In May 2013, the Veteran filed a claim for service connection for a skin condition A June 2013 VA treatment indicated that there was no evidence of rashes or suspicious lesions present. During a January 2014 VA examination, the Veteran reported that he developed a rash on both arms after returning from Desert Storm. He stated that the rash came and went and that he did not have a breakout at that time. The diagnosis was dermatitis of the bilateral upper extremities. The examiner opined that the disability pattern related to his skin and anemia was diagnosable but a medically unexplained chronic multi-symptom illness of unknown etiology. A July 2016 treatment record noted that the Veteran had two skin tags on the back side of his neck. He denied having a rash or change in pigment in July 2017, October 2017, November 2017, December 2017, March 2018, June 2018, June 2018, December 2018, February 2019, May 2019, August 2019, November 2019, December 2019, January 2020, February 2020, March 2020, April 2020, and May 2020. VA treatment records also show that, in October 2018, the Veteran was approved for dermatology evaluation and treatment of rash and other nonspecific skin eruption at a non-VA provider. The Board notes that he has not submitted or identified any private treatment records related to his claimed skin disability. During a November 2020 VA examination, the Veteran reported having intermittent eruptions of dry, scaly, rash, with hypopigmented circular lesions to the bilateral forearms. He stated that he had significant exposure to toxins during his deployment in Iraq. He reported showering with water that was pumped through trucks that had previously carried diesel fuel and that his symptoms began after that. He stated that the condition was exacerbated in the summer months with heat. He also reported the onset of a firm, intermittently painful nodule on his left upper arm that he first noticed after receiving an Anthrax vaccination during his deployment. On examination, it was noted that he had multiple hypopigmented areas (too numerous to count) of the hand and forearms, and a mild non-erythematous rash on the bilateral hands. The examiner also noted that he had what appeared to be a lipoma, which he stated was due to an Anthrax vaccine during deployment. The diagnoses were dermatitis of the bilateral forearms and a left upper arm nodule/lipoma. The November 2020 VA examiner opined that the Veteran’s skin disability was at least as likely as not incurred in or caused by service. The examiner noted that skin disorders were on the list of presumptive illness seen in Veterans who served in Southwest Asia and that Gulf War veterans were twice as likely to be diagnosed with seborrheic dermatitis. The examiner also noted that the Veteran reported having intermittent rash since service and that VA treatment records noted the use of topical corticosteroids. In the January 2021 supplemental statement of the case (SSOC), the Agency of Original Jurisdiction (AOJ) denied service connection for a skin disability because chronicity of at least six months had not been established by objective medical evidence. The Board notes, however, that the Veteran’s skin disability is capable of lay observation and that he has reported intermittent flare-ups of the skin disability since service. The Board has no reason to doubt the credibility of his statements. Furthermore, the November 2020 VA examiner identified the disability on examination and opined that it was incurred in or related to service. Based on the foregoing, the Board finds that the evidence for and against the claim for service connection for a skin disability is at least in relative equipoise. Resolving reasonable doubt in the Veteran’s favor, the Board finds that service connection for a skin disability is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Service Connection – Hypothyroidism, Anemia, Diabetes Mellitus, and a Back Disability The Veteran maintains that his hypothyroidism, anemia, diabetes mellitus, and back disability were incurred in or are related to active service. During the June 2019 Board hearing, he testified that he was exposed to chemicals, oil fires, burn pits, and smoke during his service in the Persian Gulf. He also stated that when he returned from service, he was diagnosed with hypothyroidism, anemia, and diabetes mellitus. Regarding his back disability, he stated that he had to do a lot of heavy lifting during service and that he had back pain but did not complain or seek any treatment for it. The Veteran’s service treatment records are unremarkable for any complaints, treatment, or diagnoses related to hypothyroidism, anemia, diabetes mellitus, and a back disability. At an April 1992 periodic examination for the Army National Guard, his spine and endocrine system were normal. A urinalysis was negative for sugar and albumin. He denied having or having had recurrent back pain, thyroid trouble, and sugar in his urine. He indicated that he had frequent urination when he drank a lot of fluids. Post service, a March 2006 VA treatment record noted that the Veteran was diagnosed with macrocytic anemia. In April 2006, he complained of a history of low back pain for the past five or six months. It was noted that X-rays in February 2006 showed minimal degenerative changes at L4-L5 and L5-S1. In July 2006, he was diagnosed with hypothyroidism. In June 2008, he reported that he had been diagnosed with diabetes earlier that month. In November 2009, it was noted that a CT of the cervical spine revealed degenerative joint disease. A June 2010 X-ray showed degenerative changes of the thoracic spine. The report of a January 2014 VA examination noted that the Veteran had been diagnosed with diabetes mellitus, anemia, hypothyroidism, and degenerative arthritis of the spine. The examiner opined that the disability pattern related to his skin and anemia was diagnosable but a medically unexplained chronic multi-symptom illness of unknown etiology. The examiner indicated that diabetes mellitus, hypothyroidism, and the back disability were conditions with clear and specific etiologies and were not related to the Gulf war or hazardous environmental exposure during the Gulf War. The examiner explained that diabetes mellitus was due to an insulin problem; hypothyroidism was due to low thyroid hormone; and the back disability was to due osteoarthritis. In November 2019, the Board remanded the claims for additional VA examinations and medial opinions. The Board found that the January 2014 VA examiner’s opinion lacked adequate rationale and did not sufficiently address the Veteran’s lay statements and contentions regarding the onset and continuity of his symptoms. The report of a November 2020 VA examination for thyroid conditions noted that the Veteran was diagnosed with hypothyroidism in 2006. He reported that he was diagnosed around 2007 and was started on thyroid replacement. He stated that he continued with medication and was asymptomatic with the exception of experiencing fatigue. The examiner opined that the claimed condition was less likely than not that incurred in or related to service. The examiner noted that the Veteran reported significant exposure to environmental hazards and toxins during his deployment, but that he was not diagnosed with hypothyroidism until 15 years after service. The examiner noted that hypothyroidism was not a presumptive illness with Gulf War service, and that several studies found no evidence of increased prevalence of hypothyroidism in Gulf War veterans. The examiner further stated that hypothyroidism was a diagnosable illness resulting from inadequate thyroid stimulating hormone levels. The report of a November 2020 VA examination for anemia noted that the Veteran was diagnosed with anemia in 2006. He reported that the diagnosis was based on routine blood work. He stated that since his diagnosis, he had experienced symptoms of fatigue. The examiner opined that anemia was less likely than not that incurred in or related to service. The examiner noted that the Veteran reported significant exposure environmental hazards and toxins during his deployment, but that he was not diagnosed with anemia until 15 years after service. The examiner noted that hypothyroidism was a risk factor for the development of anemia, that a 2016 colonoscopy noted diverticulitis, and that anemia was not a presumptive illness with Gulf War service. The examiner also noted that several studies found no evidence of increased prevalence of an anemia related illness in Gulf War veterans. The examiner further stated that anemia was a diagnosable illness with a clear and specific etiology, i.e., gastrointestinal blood loss and hypothyroidism, and therefore was less likely than not incurred during or caused by service. The report of a November 2020 VA examination for diabetes mellitus noted that the Veteran was diagnosed in 2008. The examiner opined that the claimed condition was less likely than not that incurred in or related to service. The examiner noted that the Veteran reported significant exposure to environmental hazards and toxins during his deployment, but that he was not diagnosed with diabetes mellitus until 17 years after service. The examiner noted that there was no evidence of treatment or diagnosis of diabetes mellitus during service, and that the Veteran’s race and smoking were significant risk factors for the development of diabetes mellitus. The examiner also noted that diabetes mellitus was not a presumptive illness with Gulf War service and that several studies found no evidence of increased prevalence of diabetes mellitus in Gulf War veterans. The examiner further stated the Veteran’s risk factors included his weight, smoking, and race, and that the condition was less likely incurred in or caused by service. The report of a November 2020 VA examination for the back noted that the Veteran was diagnosed with degenerative arthritis of the spine in 2014, intervertebral disc syndrome (IVDS) in 2020, and spinal stenosis in 2020. The Veteran reported that the onset of his low back symptoms was in 2006. He attributed his symptoms to his military occupation specialty (MOS) as a truck tanker supply unit that required frequent strenuous activity while fueling and repeated to exposure to rough roads and jarring while riding in trucks. He stated that since initial onset, he had required three epidurals for back pain and experiencing numbness and tingling radiating into his right hip and leg. The examiner opined that the claimed condition was less likely than not that incurred in or related to service. The examiner noted that the Veteran reported experiencing back pain during service and did not seek medical attention. The examiner noted, however, that VA treatment records dated in 2006 indicated that he reported the pain had been present for three to four months. The examiner stated that although his MOS potentially subjected him to heavy physical demands, which was a risk factor for the development of osteoarthritis, the claims file was silent on low back pain during active duty and from 1991 to 2006. Furthermore, VA treatment records indicated that his back pain began in 2005, 14 years after service, and X-rays at that time only showed mild degenerative arthritis of the spine. Therefore, the examiner opined that it was more likely than not that his back disability was a result of post separation body habitus, social, occupational, and recreational activities, and less likely incurred in or caused by service. In this case, the Board finds the most probative evidence weighs against the claims. The first complaints and objective evidence of the claimed disabilities occurred many years after service. The passage of time between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Furthermore, the November 2020 VA examiner opined that the Veteran’s hypothyroidism, anemia, diabetes mellitus, and back disability were less likely than not related to service. The examiner considered and addressed the relevant evidence of record, the Veteran’s contentions, and provided rationale for her opinions. For this reason, the Board finds the VA examiner’s opinions significantly probative. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The only medical opinion supporting the Veteran’s claim is the January 2014 VA examiner’s opinion that anemia was part of a medically chronic multi-symptom illness of unknown etiology. However, the January 2014 VA examiner provided no rationale for her opinion. On the other hand, the November 2020 VA examiner clearly indicated that anemia was a diagnosable condition with a clear etiology, i.e., gastrointestinal bleed and hypothyroidism. Regarding anemia, the Board finds the November 2020 VA examiner’s opinion more probative as it is consistent with the underlying medical record and is supported by adequate rationale. The Board has also considered the lay evidence of record. The Veteran is competent to describe what he has personally observed or experienced. However, the ultimate questions of diagnoses and etiology in this case extend beyond an immediately observable cause-and-effect relationship and are beyond the competence of lay witnesses. Accordingly, the Board finds that the preponderance of the evidence is against the claims and entitlement to service connection for hypothyroidism, anemia, diabetes mellitus, and a back disability is not warranted. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 49. Kristin Haddock Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Mishalanie, 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.