Citation Nr: 21027358 Decision Date: 05/05/21 Archive Date: 05/05/21 DOCKET NO. 15-27 493A DATE: May 5, 2021 ORDER Service connection for a skin condition, to include left axillary lipoma, is denied. An increased rating of 60 percent (but no greater, and this is the maximum allowable rating by law) for a duodenal ulcer condition, effective July 29, 2011, is granted. FINDINGS OF FACT 1. The evidence of record establishes the Veteran has a currently diagnosed left axillary lipoma condition; however, the evidence does not establish that the Veteran experienced this condition at any time during active service, and the condition is neither caused nor aggravated by his service-connected duodenal ulcer or any required treatments for that condition. 2. Affording the Veteran the benefit of doubt, the evidence of record is evenly balanced for and against ("in relative equipoise") a finding that the symptoms associated with his duodenal ulcer more closely approximate a 60 percent rating because his symptoms are severe, with the Veteran experiencing pain on a near constant, daily basis, weight loss, acid reflux, difficulties swallowing, and nausea, with little relief from standard ulcer treatments. See April 2019 Board of Veterans' Appeals (Board) hearing; October 2020 VA examination. The Veteran's condition also causes significant functional impairment in his ability to socialize and work due to the sometimes, debilitating nature of his condition. Id. This is the highest rating allowed under Diagnostic Code (Code) 7305. CONCLUSIONS OF LAW 1. The criteria have not been met for service connection for a skin condition, to include left axillary lipoma have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 2. The criteria have been met for an increased rating of 60 percent (but no greater, and this is the maximum allowable rating by law) for a duodenal ulcer condition, effective July 29, 2011. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.2, 4.3, 4.7, 4.10, 4.114, Code 7305. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1954 to June 1957. These matters are before the Board on appeal from a January 2012 rating decision by the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). An April 2019 Board hearing was conducted before the undersigned; a transcript has been associated with the record. In March 2020, the Board remanded the Veteran's claims for further development. Insert dates of service and jurisdictional information only where relevant to the adjudication of the issues on appeal. The Board takes pause here express its sincere apologies and regret to the Veteran for the significant length of time he has waited to receive a final decision on his claims herein. The Board assures the Veteran that every effort was made to ensure an accurate and complete adjudication of his claims. 1. Service connection for a skin condition, to include left axillary lipoma is denied. Legal Criteria Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection requires evidence showing: (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a nexus between the current disability and the disease or injury incurred or aggravated in service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Establishing secondary service connection requires evidence of: (1) a current disability (for which secondary service connection is sought); (2) a service-connected disability; and (3) that the current disability was either caused or aggravated by the service-connected disability. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995). When there is an approximate balance of positive and negative evidence regarding the merits of an issue, the benefit of the doubt shall be given to the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. If the preponderance of the evidence is against the claim, the claim is to be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board has reviewed all evidence in the claims file, with an emphasis on the evidence relevant to these appeals. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Board will summarize the relevant evidence as appropriate and the analysis will focus on what the evidence shows, or fails to show, as to the claims. Factual Background The Veteran has asserted that his lipoma condition is caused by his ulcer medication and has not specifically asserted that he has a claim for direct service connection except that he has taken ulcer therapies since serving on active duty. The Veteran's service treatment records (STRs) are silent for any treatment for lipomas or neoplasms of the skin during active military service. The Veteran attended a December 2011 VA examination for his lipoma condition. The examiner diagnosed the Veteran with recurrent atypical lipoma to his left axillary and noted an original diagnosis in 1992. The Veteran stated his lipoma was due to the medication used to treat his ulcer. The examiner did not provide a direct service connection opinion but opined that the Veteran's lipoma condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. The examiner's rationale or reasoning was that the exact cause of lipomas is unknown and that lipomas tend to run in families so genetic factors likely play a role in their development. The examiner cited a research article but did not describe its contents further. The Veteran stated in his August 2015 VA Form 9 (Board appeal) that his observable symptoms include significant weight loss. He also stated that his lipoma is due to his medication that he takes for his duodenal ulcer. At the April 2019 Board hearing, the Veteran stated that it is his belief that his lipomas are due to his ulcer medication. He did not describe any incidents of lipomas while in active military service. The Veteran attended an October 2020 VA examination for his lipoma condition. The examiner confirmed a diagnosis of left axillary lipoma, with initial diagnosis in the 1980s. The Veteran reported that, while serving in the military, he consumed a lot of Maalox to help his upset stomach. He again reported that it is his belief that the Maalox caused him to develop the lipoma. He also reported that his condition has progressed or worsened. The examiner opined that the Veteran's lipoma condition is at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner's rationale was that the Veteran's medical records support that the Veteran's current lipoma condition is at least as likely as not incurred in or caused by the skin neoplasms during service and that the Veteran served on active duty from July 1954 to July 1957. [The Board notes here that as indicated above, the Veteran's service records show no evidence of skin neoplasms during service.] The examiner also opined that the Veteran's claimed condition is less likely than not proximately due to or the result of the Veteran's service-connected duodenal ulcer. The examiner's reasoning was that the Veteran's lipoma condition is not likely caused or aggravated by the Veteran's ulcer and there is no medical correlation. VA obtained a November 2020 addendum opinion from the October 2020 VA examiner on the secondary service connection opinion. The examiner further opined that the Veteran's lipomas are at least as likely as not proximately due to the medication the Veteran takes for his duodenal ulcers. The examiner's reasoning was stated that there is no medical rationale to support that lipoma formation is caused by medications taken for ulcer as reported by the Veteran so secondary service connection or aggravation cannot be established. The examiner goes on to establish a baseline for his lipoma condition. VA also obtained a December 2020 addendum medical opinion from the October and November 2020 examiner. The examiner stated there was no error in the opinion and stated that the Veteran's service records do not show any medical complaints for lipoma or any condition of this nature during the Veteran's time in service. The examiner went on to state that the first documentation of lipoma diagnosis was 1992, some 35 years after the Veteran's service. The examiner again stated that a negative opinion was given because the Veteran's lipomas are not as likely proximately due to the medication the Veteran takes for his duodenal ulcers. The examiner stated that no medical literature or rational supports that the formation of an axillary lipoma is caused or aggravated by consumption of medication to treat stomach ulcers. [CONTINUED ON NEXT PAGE] Analysis First, the Board notes that the Veteran has a current diagnosis of left axillary lipoma; thus, he meets the first element for service connection on both a direct and secondary basis. However, the Veteran has not asserted, and the evidence of record does not provide any evidence of an event, injury, or disease relating to lipomas during the Veteran's active duty service. Therefore, the Board cannot grant the Veteran's claim on a direct service connection basis. Here, the Board must also point out that the October 2020 VA examination and November and December 2020 addendum opinions may have caused significant confusion to the Veteran, as well as others who have attempted to understand the examiner's opinions and rationale. As these opinions relate to the Veteran's direct service connection claim, the Board cannot give any probative value to these opinions. It is unclear what the examiner was attempting to say, but what is clear from the record is that there is no evidence of an in-service event, injury, or disease relating to his lipoma condition. Regardless of the examiner's opinion that it is at least as likely as not incurred in or related to service, the examiner's rationale in the addendum opinions directly contradicts that statement because she states there is not in-service incurrence. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based on an inaccurate factual premise has no probative value). Thus, this opinion provides no link between the Veteran's current diagnosis and his military service. The Veteran has also asserted that his lipoma condition is caused by or aggravated by the medication he has taken for many years for his ulcer. Here, when taken as a whole, the October 2020 VA examination and November and December 2020 addendum opinions provide a clear indication that there is no medically sound causal link that the Veteran's lipoma was caused or aggravated by his medication or duodenal ulcer. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (explaining that VA must read an examination report or opinion as a whole). Although confusing, no reasonable reader would conclude that the examiner was opining that there is a medical link or causal link between the Veteran's ulcer condition and medication and his lipoma. The examiner reasoned that there is no medical literature to support such a connection and no evidence within the claims file contradicts that statement. Therefore, the Board give some probative weight to the examiner's opinion. The December 2011 VA examination and opinion also provide some probative weight that the Veteran's lipoma condition is more likely related to genetics than any other cause, but this opinion did not directly address the Veteran's specific assertion. The Board understands that the it is the Veteran's belief that his lipomas are caused or aggravated by the medication for his ulcers (which he has undoubtedly taken for many decades), but the Board cannot give the Veteran's opinion any probative weight. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007) (explaining that lay persons are qualified to report observable symptoms and medical events but not to provide medical opinions about complex medical questions). Accordingly, the preponderance of evidence is against finding that the Veteran's lipoma condition is related to his military service, on either a direct or secondary service connection basis. The Board sincerely appreciates the Veteran for his honorable service and regrets a more favorable decision could not be reached for this claim. Again, the Board apologizes for the amount of time the Veteran has waited for this decision to be reached. [CONTINUED ON NEXT PAGE] An increased rating of 40 percent (but no greater) for a duodenal ulcer condition, effective July 29, 2011, is granted. For the reasons outlined in more detail above in the Findings of Fact section, the appeal for an increased rating for duodenal ulcer, on the merits, is granted. VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Williams, 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.