Citation Nr: 22016124 Decision Date: 03/21/22 Archive Date: 03/21/22 DOCKET NO. 15-36 170 DATE: March 21, 2022 ORDER The claim for service connection for a heart disability is denied. The claim for service connection for a skin disability is denied. FINDINGS OF FACT 1. The evidence of record persuasively weighs against finding that a heart disability began during active service or is otherwise related to an in-service injury or disease or is proximately related to a service-connected disability. 2. The evidence of record persuasively weighs against finding that a skin disability began during active service or is otherwise related to an in-service injury or disease or is proximately related to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a heart disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for a skin disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1969 to August 1973. He died in February 2018 and the appellant is his surviving spouse. The claim was remanded by the Board in May 2019 and August 2021 for additional development and has been returned now for further appellate action following substantial compliance with the remand order. Service Connection 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 also be granted for a disability that is proximately due to or the result of an established service-connected disability. 38 C.F.R. § 3.310. This includes disability made chronically worse by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). 1. Entitlement to service connection for a heart disability The Veteran contends that he incurred a heart disability as a result of military service, to include conceded herbicide exposure, or, in the alternative, as a result of service-connected diabetes mellitus type II (herein diabetes). The Board concludes that although the record demonstrates a diagnosis of a heart condition during the pendency of this appeal, the evidence weighs against a finding of presumptive, direct, or proximate service connection. Regarding presumptive service connection, the Board notes that there is no evidence that the Veteran had ischemic heart disease, or any heart disability considered by regulation to be presumptively service-connected due to herbicide exposure. VA and private treatment records are negative for such a diagnosis and an August 2021 VA examiner stated that there is no evidence to support a diagnosis of ischemic heart disease, obstructive coronary artery disease, or myocardial infarction (MI) noted in the claims folder. As a result, presumptive service connection due to herbicide exposure is not warranted in this claim. The Board acknowledges the Veteran's contention that the 2021 VA examiner is not qualified to answer the questions regarding diagnosis in this claim as they are medically complicated. However, the Veteran and his representative did not specifically identify what education or knowledge the VA examiner was lacking. Furthermore, the Board finds that there is no evidence that the 2021 VA examiner, a Certified Physician's Assistant, does not possess the requisite medical training or knowledge to determine whether the Veteran has a disability listed in the VA regulations for presumptive service connection. Regarding direct service connection, the Veteran does not contend, nor does the evidence demonstrate, that his heart disability began during active duty service or for many years thereafter. The Board concludes that, while the Veteran had a current diagnosis of diastolic heart failure with associated atrial fibrillation, and evidence shows that he was exposed to herbicides during service, the evidence of record persuasively weighs against finding that the Veteran's heart disability began during service or is otherwise related to an in-service injury, event, or disease. The evidence does not contain any competent and credible evidence linking the Veteran's current heart disabilities to herbicide exposure. Finally, the Veteran contends that he incurred a heart disability as a result of service-connected diabetes. However, there is no competent or credible evidence of record linking his heart disability to a service-connected disability, including diabetes. Furthermore, an April 2020 VA examiner held that his heart disability is not proximately related to diabetes. The examiner explained that the Veteran's diabetes was relatively mild early in the disease leading up to and at the time of the development of heart failure. Further, the examiner opined that Veteran's cardiac conditions of heart failure and atrial fibrillation were more likely than not developed as a consequence of conditions unrelated to his service-connected disabilities, such as pre-existing morbid obesity, pre-existing hypertension, and cigarette smoking. Common medical knowledge, the examiner stated, supports that this Veteran's the most significant risk for development of his form of cardiac disease is hypertension and obesity. The examiner stated that there is no evidence that the Veteran's conditions were aggravated by his diabetes or service-connected peripheral vascular disease (PVD), left lower leg below-the-knee amputation, and/or blood clot disorder. The examiner noted that when the Veteran's diabetes was diagnosed, it was controlled merely by a modified diet, but his PVD was already advanced. While the Veteran certainly believes that his heart disability is related to military service or a service-connected disability, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body, anatomical relationships, and interpretation of complicated diagnostic medical testing. As he has not been shown to possess such knowledge or medical training, the issue of etiology of his heart disability is outside of his competence. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the VA opinion evidence in this claim, which is against the finding of service connection for a heart disability. Given the lack of medical evidence in support of the claim, the evidence is against a finding of a nexus between the Veteran's current heart disability(s) and military service or service-connected disability(s). Accordingly, the Board must conclude that the preponderance of the evidence is against the claim, and it is, therefore, denied. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt rule enunciated in 38 U.S.C. § 5107(b). However, as there is not an approximate balance of evidence, that rule is not applicable in this case. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). 2. Entitlement to service connection for a skin disability The Veteran contends that he incurred a skin disability as a result of military service, to include conceded herbicide exposure, or, in the alternative, as a result of service-connected diabetes. The Board concludes that although the record demonstrates a diagnosis of dermatitis during the pendency of this appeal, the evidence weighs against a finding of direct or proximate service connection. Regarding direct service connection, service treatment records are negative for any complaints, treatment, or diagnoses of a skin disability and a 1973 separation examination and report of medical history revealed a normal skin examination. The Board acknowledges the Veteran's reports during a 2015 VA examination that his rashes developed during military service and that he did not seek treatment because there was no time. However, in a 1984 treatment record, the first evidence of record of treatment for a skin disability, it is noted that he specifically denied developing any skin symptoms during military service and stated that his skin issues began after discharge. The Board concludes that, while the Veteran has a current diagnosis of dermatitis, and evidence shows that he was exposed to herbicides during service, the evidence of record persuasively weighs against finding that the Veteran's dermatitis began during service or is otherwise related to an in-service injury, event, or disease. The evidence does not contain any competent and credible evidence linking the Veteran's current dermatitis to herbicide exposure. Finally, the Veteran contends that he incurred a skin disability as a result of service-connected diabetes. However, there is no competent or credible evidence of record linking his dermatitis disability to herbicide exposure. Furthermore, a March 2015 and an October 2021 VA examiner held that his dermatitis was not proximately related to diabetes. The examiners explained that the medical literature does not support a finding of an etiologically link between dermatitis and diabetes. Furthermore, the examiner found the lack of in-service symptoms, treatment, or diagnosis of a skin disability during service and for over a decade post-discharge weighed against a finding of service connection for dermatitis. The Board acknowledges the Veteran's contention that the 2021 VA examiner is not qualified to answer the questions regarding etiology as they are medically complicated. However, the Veteran and his representative did not specifically identify what education or knowledge the VA examiner was lacking. Furthermore, the Board finds that there is no evidence that the 2021 VA examiner, a Certified Physician's Assistant, does not possess the requisite medical training or knowledge to determine whether the Veteran has a skin disability etiologically related to military service or a service-connected disability. The 2021 VA examiner correctly stated that although he was credible to report symptoms of intermittent rashes, this Veteran was not qualified to attribute symptoms to a diagnosis. Indeed, while the Veteran certainly believes that his skin disability is related to military service or a service-connected disability, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body, anatomical relationships, and interpretation of complicated diagnostic medical testing. As he has not been shown to possess such knowledge or medical training, the issue of etiology of his skin disability is outside of his competence. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the VA opinion evidence in this claim, which is against the finding of service connection for a skin disability. Given the lack of medical evidence in support of the claim, the evidence is against a finding of a nexus between the Veteran's current skin disability and military service or service-connected disability(s). Accordingly, the Board must conclude that the more probative evidence is against the claim, and it is, therefore, denied. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt rule enunciated in 38 U.S.C. § 5107(b). However, as there is not an approximate balance of evidence, that rule is not applicable in this case. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Cynthia M. Bruce Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. B., 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.