Citation Nr: 25005378 Decision Date: 04/22/25 Archive Date: 04/22/25 DOCKET NO. 09-30 031 DATE: April 22, 2025 ORDER Entitlement to service connection for alopecia is denied. FINDING OF FACT The evidence of record persuasively weighs against finding that the Veteran's diagnosed alopecia or hair loss disability began during service, or is otherwise related to an in-service injury, disease, or exposure. CONCLUSION OF LAW The criteria for entitlement to service connection for alopecia have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in the United States Army from February 1987 to May 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) that denied entitlement to service connection for bilateral shoulder condition and memory loss/anger management/light sensitivity. This matter of alopecia has been before the Board on multiple occasions including in July 2022, where the Board issued a decision that denied entitlement to service connection for alopecia. The Veteran appealed the denial to the United States Court of Appeals for Veterans Claims (CAVC). In May 2024, CAVC issued a memorandum decision in which it remanded the claim back to the Board. CAVC requested for the Board to obtain a new VA examination and opinion for alopecia. In September 2024, the Board remanded the claim of entitlement to service connection for alopecia in order to obtain a new medical opinion. 1. Entitlement to service connection for alopecia is denied. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. 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). When evaluating evidence for a claim for disability benefits, the factual basis may be established by medical evidence, competent lay evidence, or both. 38 C.F.R. §. 3.307(b). In terms of lay evidence, the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Moreover, if the Board concludes that the lay evidence presented by a veteran is credible and ultimately competent, the lack of contemporaneous medical evidence should not be an absolute bar to the veteran's ability to prove his claim of entitlement to disability benefits based on that competent lay evidence. Id. Competent testimony is thus limited to that which the witness has actually observed and is within the realm of his personal knowledge. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis; or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In order for a medical opinion to be given weight, it must be: (1) based upon sufficient facts or data; (2) the opinion is the product of reliable principles and methods; and (3) the expert witness has applied the principles and methods reliable to the facts of the case. Nieves-Rodríguez v. Peake, 22 Vet. App. 295, 302 (2008). Other factors that may be considered in assessing the probative value of a medical opinion include a physician's access to the claims file or pertinent evidence, the thoroughness and detail of the opinion, the accuracy of the factual premise underlying the opinion, the scope of examination, the rationale for the opinion offered, the degree of certainty provided, and the qualifications and expertise of the examiner. Prejean v. West, 13 Vet. App. 444, 448-49 (2000). In circumstances when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). More precisely, the benefit-of-the-doubt rule applies if the competing evidence is in "approximate balance", which can be interpreted as evidence that is "nearly equal". Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021). In June 2014, the Board remanded the before-mentioned claims of bilateral shoulder disabilities and included the claim for service connection for an undiagnosed illness, to include hair loss, to attempt to obtain any outstanding private treatment record and to obtain a more thorough VA examination. In December 2021, and after previous Board remands in June 2014, September 2015, March 2017, and December 2017, the Board remanded the claim of entitlement to service connection for alopecia. The Board indicated that the August 2019 VA medical opinion for alopecia was inadequate because no discussion was provided on the possible relationship between the Veteran's hair loss and his conceded exposure to environmental hazards while stationed in Southwest Asia. In March 2022, the Veteran underwent a skin diseases VA examination, and an opinion was issued in relation to his claim for service connection for alopecia. The VA examiner opined that the Veteran's diagnosed alopecia was less likely than not incurred in or caused by service and Southwest Asia exposure. In April 2022, the RO issued its supplemental statement of the case. In July 2022, the Board denied entitlement to service connection for alopecia. The Board indicated that the collective medical opinions rendered by the VA examiners are adequate and persuasive. Thus, the Board assigned greater probative value to the VA opinions than the Veteran's lay statements. In May 2024, CAVC issued a memorandum decision. CAVC indicated that it remanded the claim of entitlement to service connection for alopecia for the Board to obtain a new VA examination. CAVC mentioned that the VA examiner provided an inadequate rationale for treating the Veteran's lay statements inconsistently. CAVC highlighted that VA medical records from 2001 show that the Veteran reported that his hair had been thinning since January 1992. Also, CAVC mentioned that although the March 2022 VA examiner noted the 2001 VA medical record, the examiner discounted it because "the provider did not provide the objective exam" to confirm the Veteran's statement. CAVC remarked that the VA examiner found that the Veteran had onset for alopecia in 2008. According to CAVC, the inconsistency is that the only evidence that the VA examiner referenced for the 2008 date of onset was the Veteran's self-report. Thus, the VA examiner accepted one of the Veteran's lay statements about the onset of his symptoms but rejected another with no medical analysis to explain the inconsistency. In September 2024, the Board, upon receipt of the mandate from CAVC, remanded the claim of entitlement to service connection for alopecia. In essence, the Board requested a remand to obtain a new medical opinion that treated the Veteran's lay statements consistently in terms of onset of his disability. Also, the Board ordered for the examiner to consider any TERA in Southwest Asia. In September 2024, the VA examiner opined that the claimed alopecia condition was less likely than not (likelihood is less than approximately balanced or nearly equal) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner noted a current diagnosis of male pattern baldness. Also, the VA examiner indicated that the Veteran's service treatment records do not show any symptoms relating to male pattern baldness. The VA examiner mentioned that VA medical records from 2001 show that the Veteran reported that his hair had been thinning since January 1992. The VA examiner commented that this would mean that the condition began after service had ended. The VA examiner mentioned that this condition is due to the Veteran's family genetics and changes in male sex hormones. Thus, the VA examiner concluded that a nexus cannot be made. The VA examiner also opined that the claimed condition of alopecia was less likely than not caused by the indicated toxic exposure risk activities, after considering the total potential exposure through all applicable military deployments of the Veteran and the synergetic, combined effect of all toxic exposure risk activities of the Veteran. The VA examiner noted that the Veteran served during the Gulf War era in the United States Army from February 1987 to May 1991. The VA examiner indicated that medical research does not show any relationship or direct link between male pattern baldness and the exposures reported in the toxic exposure risk activities (TERA) memorandum such as particulate matter. The VA examiner concluded that this condition is due to Veteran's family genetics and changes in male sex hormones. In February 2025, the RO issued its supplemental statement of the case in which it denied entitlement to service connection for alopecia. The RO indicated that it was unable to establish service connection because the evidence of record does not show that his male pattern baldness is related to his military service. In March 2025, the Veteran's representative submitted an appellate brief and requested for the Board to review this claim. Upon review of the evidence of record, the Board finds that entitlement to service connection for alopecia is not warranted. It is important to mention that the Veteran has been diagnosed with alopecia. Thus, the element of a current disability for a service connection claim is met. However, there is controversy as to the onset of the current alopecia condition and whether it is related to the Veteran's time in service. After various inadequate VA medical opinions, the September 2024 VA medical opinion concluded that the Veteran's alopecia condition is less likely than not incurred in or caused by the claimed in-service injury, event or illness. Equally, the VA examiner determined that the Veteran's claimed condition is not related to any of the conceded TERA. Pursuant to the Board's mandate in the September 2024 decision, the examiner acknowledged the Veteran's lay statements regarding onset in 1992. However, according to their criteria, the Veteran's alopecia condition is due to family genetics and/or changes in male sex hormones. Also, the VA examiner cited that the earliest report of the Veteran of onset of a hair loss disability was in 1992, after he had left service. Likewise, the examiner explained that medical studies have not shown that alopecia is caused by exposures such as fine particulate matter. The Board is persuaded by the examiner's explanations after considering the Veteran's specific circumstances and medical history. The Board considered the Veteran's lay assertions regarding onset of his alopecia condition. However, the Board finds that while the Veteran is competent to report observable symptoms and when they began, in order to determine if it is related to an in-service incurrence, that cannot be based on lay observation alone. See Jandreau v. Nicholson, supra. Instead, such a determination must be made by a medical professional with appropriate expertise. Id. In this regard, the Board finds the objective findings contained in the September 2024 VA medical opinion to be more probative. Given the foregoing, as a nexus between service and the Veteran's current alopecia is not demonstrated, the Board must find that the evidence persuasively weighs against finding that the criteria necessary to grant service connection are met. ? Accordingly, the benefit of the doubt doctrine does not apply, and the claim must be denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). DAVID L. WIGHT Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Colon, Ivan M. 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.