Case A26028939

M. C. GRAHAM · 2026 · Case ID: A26028939

MIXED

Summary

The Veteran served with multiple periods of service between October 1981 and July 2002. The Veteran appeals the denial of service connection for several conditions, including anemia, colon disability, breast disability, and hypothyroidism, and seeks service connection for right and left knee psoriatic arthritis, right and left hand psoriatic arthritis, thoracolumbar psoriatic arthritis, psoriasis scars on the elbows, hands, and ear, and bilateral cerumen impaction. The Veteran also withdrew her appeal for postmenopausal bleeding. The Board granted service connection for the psoriatic arthritis conditions affecting the knees, hands, and thoracolumbar spine, as well as for the related scars and bilateral cerumen impaction, finding these conditions proximately due to her service-connected psoriasis. The Board denied service connection for anemia, colon disability, breast disability, and hypothyroidism, finding the evidence persuasively weighed against a service connection for these conditions. The claim for a sinus disability was remanded due to errors in previous VA medical opinions, specifically the incorrect notation of pre-existing sinus issues and the failure to adequately address the Veteran's service treatment records regarding sinus congestion.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

200608-92130

Full Decision Text

Citation Nr: A26028939
Decision Date: 03/31/26 Archive Date: 03/31/26

DOCKET NO. 200608-92130
DATE: March 31, 2026

ORDER

Entitlement to service connection for a disability manifested by postmenopausal bleeding is dismissed.

Entitlement to service connection for right knee psoriatic arthritis is granted.

Entitlement to service connection for left knee psoriatic arthritis is granted.

Entitlement to service connection for right hand psoriatic arthritis is granted.

Entitlement to service connection for left hand psoriatic arthritis is granted.

Entitlement to service connection for thoracolumbar psoriatic arthritis is granted.

Entitlement to service connection for psoriasis scars of the right and left elbow, right and left hand, and left ear is granted.

Entitlement to service connection for cerumen impaction, bilateral ears, is granted.

Entitlement to service connection for anemia is denied.

Entitlement to service connection for a colon disability, claimed as colon polyps, is denied.

Entitlement to service connection for a breast disability, claimed as fibrocystic breast disease, is denied.

Entitlement to service connection for hypothyroidism is denied.

REMANDED

Entitlement to service connection for a sinus disability is remanded.

FINDINGS OF FACT

1. At the April 2024 Board of Veterans' Appeals (Board) hearing, the Veteran explicitly, unambiguously, and with a full understanding of the consequences of such action, withdrew the issue of entitlement to a disability manifested by postmenopausal bleeding; a written statement was subsequently submitted in July 2024 confirming such withdrawal.

2. The Veteran's right knee psoriatic arthritis has been attributed to her service-connected psoriasis.

3. The Veteran's left knee psoriatic arthritis has been attributed to her service-connected psoriasis.

4. The Veteran's right hand psoriatic arthritis has been attributed to her service-connected psoriasis.

5. The Veteran's left hand psoriatic arthritis has been attributed to her service-connected psoriasis.

6. The Veteran's thoracolumbar psoriatic arthritis has been attributed to her service-connected psoriasis.

7. The Veteran's scars of the right and left elbow, right and left hand, and left ear have been attributed to her service-connected psoriasis.

8. The Veteran's ear disability diagnosed as cerumen impaction has been attributed to her service-connected psoriasis; the evidence of record persuasively weighs against finding that the Veteran has had any other ear disability, including ear infections or objective signs of related disability perceptible to an examining physician, at any time during or approximate to the pendency of the claim.

9. The evidence of record persuasively weighs against finding that the Veteran has anemia that either manifested in service or to a compensable degree within the presumptive period after separation from service; or is otherwise etiologically related to an in-service event, injury or illness.

10. The evidence of record persuasively weighs against finding that the Veteran has a colon disability, claimed as colon polyps, related to service.

11. The evidence of record persuasively weighs against finding that the Veteran has a breast disability, claimed as fibrocystic breast disease, related to service.

12. The evidence of record persuasively weighs against finding that the Veteran has hypothyroidism related to service.

CONCLUSIONS OF LAW

1. The criteria for withdrawal of the appeal as to entitlement to service connection for a disability manifested by postmenopausal bleeding, by the Veteran, have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.205.

2. Right knee psoriatic arthritis is proximately due to or the result of the Veteran's service-connected psoriasis. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310.

3. Left knee psoriatic arthritis is proximately due to or the result of the Veteran's service-connected psoriasis. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310.

4. Right hand psoriatic arthritis is proximately due to or the result of the Veteran's service-connected psoriasis. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310.

5. Left hand psoriatic arthritis is proximately due to or
3. Left knee psoriatic arthritis is proximately due to or the result of the Veteran's service-connected psoriasis. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310.

4. Right hand psoriatic arthritis is proximately due to or the result of the Veteran's service-connected psoriasis. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310.

5. Left hand psoriatic arthritis is proximately due to or the result of the Veteran's service-connected psoriasis. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310.

6. Thoracolumbar psoriatic arthritis is proximately due to or the result of the Veteran's service-connected psoriasis. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310.

7. Scars of the right and left elbow, right and left hand, and left ear are proximately due to or the result of the Veteran's service-connected psoriasis. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310.

8. Impacted cerumen, bilateral ears, is proximately due to or the result of the Veteran's service-connected psoriasis. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310.

9. The criteria for service connection for anemia are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309.

10. The criteria for service connection for a colon disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

11. The criteria for service connection for a breast disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

12. The criteria for service connection for hypothyroidism are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from October 1981 to January 1989, January 1991 to September 1991, and November 2001 to July 2002. The Board thanks the Veteran for her service.

The rating decision on appeal was issued in November 2019 and constitutes an initial decision; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies.

In the June 2020 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held on April 19, 2024.

Therefore, the Board may only consider the evidence of record at the time of the November 2019 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801. The Veteran was specifically notified at her hearing that the 90-day evidence period following the hearing, would go through July 18, 2024, and that "[s]tarting July 19, 2024, again starts a period of time where the Board cannot review evidence with respect to these claims."
.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801. The Veteran was specifically notified at her hearing that the 90-day evidence period following the hearing, would go through July 18, 2024, and that "[s]tarting July 19, 2024, again starts a period of time where the Board cannot review evidence with respect to these claims." See BVA Hearing Transcript (T.) at 2.

The Board notes that on July 19, 2024, a day after the 90-day evidence window expired, the Veteran, through her attorney, requested an extension of the evidence window. Unlike deadlines for other submissions, such as the filing of a VA Form 10182, the law does not provide for a good cause extension of the evidence submission window. 38 C.F.R. §§ 20.203(c), 20.302. Therefore, the Board has no discretion to grant such an extension in this appeal, and the request is denied. 38 C.F.R. § 20.302.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

Specific to her claim for entitlement to service connection for a sinus disability, because the Board is remanding this claim, any evidence the Board could not consider will be considered by the AOJ in the adjudication of that claim. 38 C.F.R. § 3.103(c)(2)(ii).

Withdrawal of Appeal

1. Entitlement to service connection for postmenopausal bleeding has been withdrawn.

The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.205.

An effective withdrawal of a claim on appeal must be in writing, include the name of the Veteran, the applicable Department of Veterans Affairs file number, and a statement that the appeal is withdrawn. Hembree v. Wilkie, 33 Vet. App. 1, 5-7 (2020); 38 C.F.R. § 20.205. If the appeal involves multiple issues, the withdrawal must specify that the appeal is withdrawn in its entirety, or it must list the issue(s) withdrawn from the appeal. Hembree, 33 Vet. App. at 5.

At the April 2024 Board hearing, the Veteran stated that she wished to withdraw the issue of entitlement to service connection for postmenopausal bleeding. See BVA Hearing (T.) at 6. An oral withdrawal of an appeal, such as one made at a hearing, must be (1) explicit, (2) unambiguous, and (3) done with a full understanding of the consequences of such action on the part of the claimant. DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011); Acree v. O'Rourke, 891 F.3d 1009, 1014 (Fed. Cir. 2018).

In the present case, the Veteran has explicitly, unambiguously, and with full understanding of the consequences of her action, withdrawn the issue of entitlement to service connection for postmenopausal bleeding. Moreover, in a written statement submitted by her attorney in July 2024, she confirmed that she was withdrawing this issue. The statement included the Veteran's name and VA file number and thus met the criteria for a written withdrawal of the appeal as to that issue.

As there remains no allegations of errors of fact or law for appellate consideration regarding the above-mentioned issue, the Board does not have jurisdiction over the issue, and it is dismissed.

Service Connection

Service connection
9, 1014 (Fed. Cir. 2018).

As there remains no allegations of errors of fact or law for appellate consideration regarding the above-mentioned issue, the Board does not have jurisdiction over the issue, and it is dismissed.

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).

Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). The requirement for a current disability is satisfied when the claimant has a disability at the time a claim for service connection is filed or during the pendency of the claim. McClain, supra. A disability under 38 U.S.C. § 1110 refers to functional impairment of earning capacity. Saunders v. Wilkie, 886 F.3d 1356 (2018). While the Federal Circuit in Saunders only considered pain, the Court of Appeals for Veterans Claims has held that Saunders is not limited to pain; rather, the definition of "disability" in 38 C.F.R. § 1110 includes any condition that results in "functional impairment of earning capacity." Martinez-Bodon v. Wilkie, 32 Vet. App. 393, 398 (2020).

In addition to the regulations cited above, service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id.

2. Entitlement to service connection for a right knee disability.

3. Entitlement to service connection for a left knee disability.

4. Entitlement to service connection for a right hand disability.

5. Entitlement to service connection for a left hand disability.

6. Entitlement to service connection for a low back disability.

7. Entitlement to service connection for scaring/scars disability.

8. Entitlement to service connection for an ear condition/ear infection disability.

The Board notes that service connection for the Veteran's right knee, left knee, right hand, left hand, low back, scaring/scars, and ear disabilities have all been claimed as secondary to her service-connected psoriasis. In the November 2019 rating decision on appeal, noted within the body of the decision under service connection for scarring/scars, the AOJ stated that it had been "proposed to sever service connection for your psoriasis condition." The Board notes that there is no indication in the file that the Veteran's service-connected psoriasis has been severed. Moreover, a rating decision proposing severance for psoriasis has never been issued. As service connection for psoriasis remains in effect, the Board will proceed accordingly.

Right Knee and Left knee Disabilities

The evidence of record reflects that the Veteran's right and left knee disabilities are associated with her service-connected psoriasis.

In a June 2018 VA knee examination, the Veteran was diagnosed with psoriatic arthritis of the bilateral knees. In an August 2018 VA knee examination the Veteran was diagnosed with a bilateral knee strain. In an August 2018 VA medical opinion, the examiner provided a negative etiological opinion regarding the Veteran's bilateral knee disability and service. A
Veteran's service-connected psoriasis has been severed. Moreover, a rating decision proposing severance for psoriasis has never been issued. As service connection for psoriasis remains in effect, the Board will proceed accordingly.

Right Knee and Left knee Disabilities

The evidence of record reflects that the Veteran's right and left knee disabilities are associated with her service-connected psoriasis.

In a June 2018 VA knee examination, the Veteran was diagnosed with psoriatic arthritis of the bilateral knees. In an August 2018 VA knee examination the Veteran was diagnosed with a bilateral knee strain. In an August 2018 VA medical opinion, the examiner provided a negative etiological opinion regarding the Veteran's bilateral knee disability and service. A secondary service connection opinion regarding any relationship between her knees and service-connected psoriasis was not provided. Another negative etiological opinion regarding the Veteran's bilateral knee disability and service was provided in May 2019. Secondary service connection was not addressed at that time.

In a May 2019 VA non-degenerative arthritis examination, the Veteran was diagnosed with psoriatic arthritis. The examiner noted that the Veteran's knees were affected. In a May 2019 VA medical opinion, the VA examiner noted that the Veteran's psoriatic arthritis is at least as likely as not a disability pattern or diagnosed disease that is related to specific exposure events experienced by the Veteran during her service. It was noted that the Veteran had been exposed to hazardous environmental exposures while deployed in the early 1990's handling contaminated weapons/ammo, tents, ruck sacks and radiation. Service personnel records confirm that the Veteran was part of an explosive out loading team responsible for the receipt, storage, separation and issuance of ordinance ans explosives. Her military occupational specialty included the designation of "RM" which stands for radioman.

In a June 2019 VA medical opinion, the VA examiner opined that it is at least as likely as not that the Veteran's psoriatic arthritis, bilateral knee, is proximately due to or the result of her service-connected psoriasis. The examiner noted that it is well known that psoriasis can progress to psoriatic arthritis. A nexus is established.

Resolving all doubt in favor to the Veteran, the Board finds that the evidence supports a nexus between the Veteran's claimed right and left knee disabilities and her service-connected psoriasis.

Since service connection for the Veteran's bilateral knee disability is being granted on a secondary direct basis, there is no need to consider the theory of direct service connection. Nevertheless, the Board would like to point out that the May 2019 VA examiner positively related her bilateral knee disability (psoriatic arthritis) to exposures confirmed and supported by his military occupational specialty (MOS).

As all elements of service connection have been satisfied, service connection for a bilateral knee disability is granted. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(d), 3.310. The nature and extent of the disorder is not before the Board at this time.

The Board finally notes that the Veteran was additionally diagnosed with a bilateral knee strain in her August 2018 VA examination, and there is an additional mention of osteopenia. The VA examiner specifically opined that the Veteran's osteopenia was less likely than not incurred in or caused by the Veteran's service and appears related to menopause. In a May 2019 VA medical opinion, an examiner additionally opined that it is less likely than not that the Veteran's osteopenia in the knees was incurred in or caused by military service. The Board has closely reviewed the medical and lay evidence in the Veteran's claims file and finds no evidence that may serve as a medical nexus between the Veteran's service and the specific diagnoses of knee osteopenia or strain.

In sum, while the Board grants service connection for right and left knee disabilities diagnosed as psoriatic arthritis of the bilateral knees, a separate grant for osteopenia or bilateral knee strain is not warranted.

Right Hand and Left Hand Disabilities

The evidence of record reflects that the Veteran's right and left hand disabilities are associated with her service-connected psoriasis.

In a June 2018 VA hand and fingers examination, the Veteran was diagnosed with psoriatic arthritis of the bilateral hands. In an August 2018 VA hand and fingers examination the Veteran was again diagnosed with psoriatic arthritis of the bilateral hands. In an August 2018 VA medical opinion, the examiner opined that the Veteran's condition is at least as likely as not proximately due to or the result of the Veteran's service-connected condition. The examiner noted that the Veteran appears to have psoriatic arthritis in the hands.

In a May 2019 VA non-degenerative arthritis examination, the Veteran was diagnosed with ps
Veteran's right and left hand disabilities are associated with her service-connected psoriasis.

In a May 2019 VA non-degenerative arthritis examination, the Veteran was diagnosed with psoriatic arthritis. The VA examiner noted that the Veteran's bilateral hands were affected. In a May 2019 VA medical opinion, the VA examiner noted that the Veteran's psoriatic arthritis is at least as likely as not a disability pattern or diagnosed disease that is related to specific exposure events experienced by the Veteran during her service. It was noted that the Veteran had been exposed to hazardous environmental exposures while deployed in the early 1990's handling contaminated weapons/ammo, tents, ruck sacks and radiation. In another May 2019 VA medical opinion, an examiner provided stated that while there is a confirmed diagnosis of psoriatic arthritis of the hands, there is no documentation from a treating rheumatologist, a nexus is not established. It is unclear if this was a direct or secondary opinion.

Resolving all doubt in favor to the Veteran, the Board finds that the evidence supports a nexus between the Veteran's claimed right and left hand disabilities and her service-connected psoriasis.

Since service connection for the Veteran's bilateral hand disability is being granted on a secondary direct basis, there is no need to consider the theory of direct service connection. Nevertheless, the Board would like to point out that the May 2019 VA examiner positively related her bilateral hand disability to exposures confirmed and supported by his military occupational specialty.

As all elements of service connection have been satisfied, service connection for a bilateral hand disability is granted. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(d), 3.310. The nature and extent of the disorder is not before the Board at this time.

Low Back Disability

The evidence of record reflects that the Veteran's low back disability is associated with her service-connected psoriasis.

In a June 2018 VA back examination, the Veteran was diagnosed with psoriatic arthritis of the thoracolumbar spine. In an August 2018 VA back examination, the Veteran was diagnosed with a lumbosacral strain. In an August 2018 VA medical opinion, the examiner opined that the Veteran's claimed condition is at least as likely as not the result of the Veteran's service-connected condition. The examiner noted that the Veteran's low back is not related to psoriasis but can be related to osteopenia which can be due to vitamin d deficiency which the Veteran has. The Board notes that the Veteran is not service-connected for osteopenia or vitamin D deficiency so this opinion is accorded no probative value. Additionally, the opinion regarding a relationship between the spine and psoriasis did not provide rationale so it too is accorded little probative value.

In a May 2019 VA non-degenerative arthritis examination, the Veteran was diagnosed with psoriatic arthritis. The examiner noted that the Veteran's thoracolumbar spine was affected. In a May 2019 VA medical opinion, the VA examiner noted that the Veteran's psoriatic arthritis is at least as likely as not a disability pattern or diagnosed disease that is related to specific exposure events experienced by the Veteran during her service. It was noted that the Veteran had been exposed to hazardous environmental exposures while deployed in the early 1990's handling contaminated weapons/ammo, tents, ruck sacks and radiation.

In a May 2019 VA medical opinion, the examiner opined that the claimed condition is less likely than not proximately due to or the result of the Veteran's service-connected condition because there is no confirmed diagnosis of psoriatic arthritis of the thoracic spine. However, as noted in the May 2019 VA medical examination, a diagnosis of psoriatic arthritis was provided and it was specifically noted that the Veteran's thoracolumbar spine had pain attributable to the arthritis condition and there was limitation of joint movement attributable to the arthritis condition. Therefore, this negative opinion is accorded little probative value.

Here the Veteran has clearly been diagnosed with psoriatic arthritis affecting his thoracolumbar spine, caused, at least in part, by his psoriasis. This diagnosis, by its very name, indicates a
likely than not proximately due to or the result of the Veteran's service-connected condition because there is no confirmed diagnosis of psoriatic arthritis of the thoracic spine. However, as noted in the May 2019 VA medical examination, a diagnosis of psoriatic arthritis was provided and it was specifically noted that the Veteran's thoracolumbar spine had pain attributable to the arthritis condition and there was limitation of joint movement attributable to the arthritis condition. Therefore, this negative opinion is accorded little probative value.

Here the Veteran has clearly been diagnosed with psoriatic arthritis affecting his thoracolumbar spine, caused, at least in part, by his psoriasis. This diagnosis, by its very name, indicates a relationship with psoriasis. For the foregoing reason, the claim of entitlement to service connection for a low back disability is granted on a secondary basis.

Since service connection for the Veteran's low back disability is being granted on a secondary direct basis, there is no need to consider the theory of direct service connection. Nevertheless, the Board would like to point out that the May 2019 VA examiner positively related her back disability (psoriatic arthritis) to exposures confirmed and supported by his military occupational specialty.

As all elements of service connection have been satisfied, service connection for a low back disability is granted. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(d), 3.310. The nature and extent of the disorder is not before the Board at this time.

The Board finally notes that the Veteran was additionally diagnosed with a lumbosacral strain at her June 2018 VA examination. The VA examiner specifically attributed this to nonservice-connected disabilities. The Board has closely reviewed the medical and lay evidence in the Veteran's claims file and finds no evidence that may serve as a medical nexus between the Veteran's service and the specific diagnosis of a lumbosacral strain.

In sum, while the Board grants service connection for a low back disability diagnosed as psoriatic arthritis, a separate grant for a lumbosacral strain is not warranted.

Scarring/Scars

The evidence of record reflects that the Veteran's scars of the right and left elbow, right and left hand, and left ear associated with her service-connected psoriasis.

An August 2018 VA scars/disfigurement examination was completed. The Veteran was diagnosed with psoriasis scars on the ear lobes and on her hands and elbows. The August 2018 VA examiner opined that the Veteran's claimed condition is at least as likely as not proximately due to the Veteran's service-connected condition. A June 2019 VA scars/disfigurement examination was completed. The Veteran was diagnosed with right elbow psoriasis scars, right hand psoriasis scars and left elbow psoriasis scars. Additionally, left hand and left ear psoriasis scars were diagnosed.

In a June 2019 VA medical opinion, the examiner opined that the claimed condition is at least as likely as not proximately due to or the result of the Veteran's service-connected condition. The examiner noted that the current severity of the Veteran's service-connected psoriasis warrants by proximity, association of the scars. A disorder that began subsequent to the service-connected condition and is the direct result of the antecedent condition. The medical literature supports this. A nexus is established.

Resolving all doubt in favor to the Veteran, the Board finds that the evidence supports a nexus between the Veteran's claimed scaring/scars and her service-connected psoriasis.

Since service connection for the Veteran's scarring/scars disability is being granted on a secondary direct basis, there is no need to consider the theory of direct service connection.

As all elements of service connection have been satisfied, service connection for a scars of the right and left elbow, right and left hand, and left ear is granted. See 38 U.S.C. § 1110; 38 C.F.R. § 3.310.

Ear Conditions/Ear Infections

The Veteran contends that she suffers from an ear condition/ear infection, which was incurred on active duty.

Service treatment records reflect that the Veteran sought treatment for a clogged ear and sinus trouble in December 1981 and for complaints of an earache in November 1982. It was noted that she had a buildup of wax in her ears.

A June 2018 VA ear conditions examination was completed. The examiner noted cerumen impaction in the bilateral ears.

An additional examination was completed in August 2018. The examiner noted that the Veteran did not have, nor had she ever been diagnosed with an ear or peripheral vestibular condition. It was noted that the Veteran did have symptoms of dry and scaly in her external ear canal. Her ear canal was noted to be normal. The examiner noted that with respect to the Veteran's claimed ear condition with ear infection, there is no diagnosis because the condition has resolved. However, in an August 2018 VA medical opinion, the VA examiner noted that the claimed condition is at least as likely as not due to the Veteran's service-connected condition. The examiner noted that wax build up from psoriasis causes ear infections, which in turn causes sinus infections.

In a subsequent May 2019 VA medical opinion, another VA examiner noted that there were no chronic ear infections in the file. She stated that sinusitis does not lead to ear infections and psoriasis does not lead to ear infections. She said findings on the August 2018 examination were not consistent with an ear infection.

The Veteran testified at her Board hearing that she gets buildup of ear wax. As noted, cerumen impaction of her bilateral ears was noted at her June 2018 VA examination. The requirement for a current disability is satisfied if the disability is present at any point proximate to the claim, during the claim, or the appeal period. See McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013).

Here the Veteran has clearly been diagnosed with cerumen impaction of both ears, diagnosed during the period on appeal. The August 2018 VA examiner clearly related the Veteran's wax build up as a result of her service-connected psoriasis. Her claim, for bilateral cerumen impaction is granted on a secondary basis.

Since service connection for the Veteran's bilateral ear disability, diagnosed as bilateral cerumen impaction is being granted on a secondary direct basis, there is no need to consider the theory of direct service connection.

As all elements of service connection have been satisfied, service connection for an ear disability, diagnosed as bilateral cerumen impaction, is granted. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(d), 3.310. The nature and extent of the disorder is not before the Board at this time.

However, the Board finally notes that the Veteran has also claimed recurrent ear infections as part of her claim for a bilateral ear disability. However, as noted above, the VA examinations of record did not report a diagnosis of ear infections.

The Board notes that while the Veteran is not competent to diagnose herself with ear infections, she is competent to report observable symptoms such as ear pain. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In this regard, the Board has considered whether these ear symptoms, separate from wax build-up, might constitute a disability notwithstanding the lack of any formal diagnosis of record. Cf. Saunders v. Wilkie, 886 F.3d 1356, 1368-69 (Fed. Cir. 2018) (holding that pain, even in the absence of an underlying diagnosis, can constitute a disability if it results in functional impairment). However, the record does not show that these symptoms resulted in any functional impairment to the Veteran's earning capacity such that they would be considered a disability for VA purposes.

In light of the above evidence, the Board finds that the Veteran did not have a current disability relating to her claimed ear infections during the pendency of the claim. As such, the first element of service connection is not met with respect to this specific diagnosis.

As the record weighs persuasively against a finding that the Veteran suffered from an ear infection disability during the pendency of the claim, the benefit-of-the-doubt doctrine is not for application and this portion of the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

In sum, while the Board grants service connection for an ear disability, diagnosed as bilateral cerumen impaction, a separate grant for ear infections is not
, the Board finds that the Veteran did not have a current disability relating to her claimed ear infections during the pendency of the claim. As such, the first element of service connection is not met with respect to this specific diagnosis.

In sum, while the Board grants service connection for an ear disability, diagnosed as bilateral cerumen impaction, a separate grant for ear infections is not warranted.

9. Entitlement to service connection for anemia.

10. Entitlement to service connection for colon polyps.

11. Entitlement to service connection for fibrocystic breast disease.

12. Entitlement to service connection for hypothyroidism.

The Veteran asserts that she has anemia, colon polyps, fibrocystic breast disease and hypothyroidism related to service.

Regarding the claim for service connection for anemia on a presumptive basis, the Board has also considered that where a veteran served continuously for ninety days or more during a period of war, or during peacetime service after December 31, 1946, and certain disabilities become manifest to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1131, 1133; 38 C.F.R. §§ 3.307, 3.309. However, the Veteran's treatment records do not reflect a diagnosis of or treatment for anemia until several years following separation from her last period of active service. See for example May 2006 VA treatment record. Thus, this presumption is not available to the Veteran. Id.

The Veteran testified that she was first diagnosed with anemia during service. However, the Board finds this testimony is not credible as it is inconsistent with the contemporaneous service treatment records. For example, August 1993 bloodwork indicated her blood counts (i.e., RBC (red blood cell) count) were within the normal range. A May 2002 clinical record prepared as part of her separation examination noted encouraged smoking cessation but did not reference anemia. Red blood cell counts noted in connection with separation examinations were not identified as abnormal. The records that have been associated with the claims file first note anemia in 2006, several years following separation from service.

The Board also considers the theory of entitlement to service connection on a direct basis. Combee v. Brown, 34 F.3d 1039, 1041-42 (Fed. Cir. 1994). However, the evidence does not show a causal relationship between the claimed anemia, colon polyps, fibrocystic breast disease and hypothyroidism disabilities and any other incident of active service, as will be discussed below.

The Veteran's service treatment records have been reviewed. Treatment for anemia, colon polyps, fibrocystic breast disease or hypothyroidism is not noted.

Next, and more importantly, post-service evidence does not reflect complaints or treatment associated with anemia, colon polyps, fibrocystic breast disease or hypothyroidism for several years after service discharge. For example, VA treatment records in May 2006 reflect a diagnosis of anemia, colon polyps were noted in a June 2018 VA examination, a June 2007 treatment record notes lumps in her breast and an April 20118 VA treatment record noted no symptoms of hypothyroidism. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). However, if it is determined based upon reliable evidence that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). This several year period without problems weighs against the claims.

The Veteran's reported history of continued symptomatology since active service has also been considered. Anemia and hypothyroidism are chronic diseases. However, the Board finds that to the extent that the Veteran is competent to describe observable symptoms, neither anemia nor hypothyroidism are observable diagnoses. Both require
However, if it is determined based upon reliable evidence that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). This several year period without problems weighs against the claims.

The Veteran's reported history of continued symptomatology since active service has also been considered. Anemia and hypothyroidism are chronic diseases. However, the Board finds that to the extent that the Veteran is competent to describe observable symptoms, neither anemia nor hypothyroidism are observable diagnoses. Both require blood work to diagnose. While the Veteran is competent to describe observable symptoms, there is no indication that her reported symptoms are related to diagnoses of anemia or hypothyroidism. As noted above, the service treatment records affirmatively show normal blood work which is inconsistent with continuity since service.

To the extent the Veteran's statements are inconsistent with contemporaneous records, they are not credible. In making this determination, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). Although the Veteran testified that she was treated for these conditions earlier than currently shown by the records associated with the claims file, medical evidence supporting these assertions has not been provided within the record available for the Board's review. The Veteran was provided 90 days from her hearing to obtain additional supporting medical evidence; however, no additional evidence was submitted during this time.

The Board finds the Veteran's statements asserting continuity of symptomatology of anemia, colon polyps, fibrocystic breast disease or hypothyroidism since service lack credibility and are without probative value. See, e.g. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (the Board is entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration a veteran's statements, it may consider whether self-interest may be a factor in making such statements). Continuity of symptomatology has not here been established, either through the competent medical evidence or through the Veteran's statements.

The Board next considers that service connection may be granted when the evidence establishes a medical nexus between active duty service and current complaints.

The Veteran has not submitted evidence in support of a link between her claimed anemia, colon polyps, fibrocystic breast disease or hypothyroidism and service. The Veteran is not competent to opine as to the etiology of her claimed disabilities, as she has not been shown to possess the requisite training or credentials needed to render a competent opinion as to medical diagnosis or causation. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As such, the Veteran's mere claim that her anemia, colon polyps, fibrocystic breast disease or hypothyroidism are related to her active service does not constitute competent medical evidence and lacks probative value.

As part of its duties to assist a Veteran in a claim for service connection, VA may be required to provide an examination or obtain an etiological opinion. Such is required when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the claimant's service or with another service-connected disability, and (4) insufficient competent medical evidence on file for VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006).

The Board has considered the Veteran's testimony, at her April 2024 Board hearing that her claimed disabilities may be related to exposures to hazardous materials in service. As noted above, the Veteran's service has been associated with various exposures to hazardous materials. Nevertheless, the Veteran did not raise her contentions that these claims disabilities are due to this exposure until her April 2024 Board hearing. There was no indication in the file, at the time of the November 2019 rating decision, of any relationship between the claimed disabilities and service, including her presumed exposures.

As this theory of entitlement was not raised prior to the November 2019 rating decision, the Board may not
20 Vet. App. 79 (2006).

As this theory of entitlement was not raised prior to the November 2019 rating decision, the Board may not order any development on remand as there was no pre-decisional duty to assist error.

Here, the Board does not find that there is competent and credible evidence to suggest that there may be a link between the Veteran's claimed conditions and her active duty service. As such, the Board does not find that the evidence of record requires the VA to obtain a medical examination or opinion under McLendon before deciding the Veteran's claims.

The service and post-service evidence provide particularly negative evidence against these claims. The Board has closely reviewed the medical and lay evidence in the claims file and finds no evidence that may serve as a medical nexus between the Veteran's service and her claimed anemia, colon polyps, fibrocystic breast disease and hypothyroidism. Although the Board recognizes that the Veteran is competent to report symptoms associated with these claimed disabilities, the evidence of record demonstrates that her symptoms developed several years following separation from service. There is simply nothing in the record to support a finding that her claimed problems began in or are otherwise in any way related to service.

In light of the above discussion, the Board concludes that the evidence persuasively weighs against the claims for service connection for anemia, colon polyps, fibrocystic breast disease and hypothyroidism. As such, the appeal as to these issues is denied.

REASONS FOR REMAND

1. Entitlement to service connection for a sinus disability is remanded.

A November 1980 service entrance examination noted normal sinuses. In December 1981, during her first period of active service, the Veteran was treated for a mild sinus problem. In a November 1982 service treatment record, it was noted that the Veteran's frontal and maxillary sinuses were tender to touch. In a September 1985 report of medical history, again during her first period of active service, it was noted that the Veteran had been diagnosed with sinus congestion occasionally.

A June 2018 VA sinusitis examination, noted a diagnosis of chronic sinusitis. An August 2018 VA sinusitis examination again noted a diagnosis of chronic sinusitis. The examiner provided a negative secondary medical opinion regarding any relationship between the Veteran's claimed sinus disability and her service-connected psoriasis. A direct medical opinion to service was not provided.

In a January 2019 VA medical opinion, the VA examiner incorrectly noted that the Veteran's sinus disability preexisted service; a distinction was not made regarding her three periods of service. As noted above, the first indication of a sinus disability was not noted until the Veteran was on active duty during her first period of active service. Moreover, the VA examiner incorrectly noted that the Veteran had not been seen by medical personnel for her sinus issues. This is not accurate based on a review of the Veteran's service treatment records.

A May 2019 VA medical examiner incorrectly noted that the Veteran had not been diagnosed with sinusitis. As noted, the Veteran has been diagnosed with sinusitis during the period on appeal. The May 2019 VA examiner did not provide an opinion. The requirement that a current disability exists is satisfied if the claimant had a disability at the time her claim for VA disability compensation was filed or during the pendency of the claim. McClain, 21 Vet. App. at 321.

A veteran is presumed to have been in sound condition upon entry into service when no pre-existing medical condition is noted upon entry. 38 U.S.C. § 1111. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the Veteran's disability was both pre-existing and not aggravated by service. See Wagner v. Principi, 370 F.3d 1089, 1096; Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). In this Veteran's case, her entrance examination makes no mention of sinus issues. Thus, the Board finds the Veteran is presumed sound on service, into her first period of service. As such, the January 2019
no pre-existing medical condition is noted upon entry. 38 U.S.C. § 1111. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the Veteran's disability was both pre-existing and not aggravated by service. See Wagner v. Principi, 370 F.3d 1089, 1096; Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). In this Veteran's case, her entrance examination makes no mention of sinus issues. Thus, the Board finds the Veteran is presumed sound on service, into her first period of service. As such, the January 2019 VA medical is not adequate, and an addendum opinion should have been obtained prior to adjudicating the Veteran's claim.

Remand is required to correct this pre-decisional duty to assist error.

The matters are REMANDED for the following action:

Please obtain a supplemental medical opinion to determine the nature and etiology of her sinus disability. If an examination is deemed necessary to respond to the questions posed, one should be scheduled. The clinician is asked to address the following after reviewing the claims file:

(a) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that sinusitis began during a period of active duty service, or is otherwise etiologically related to service with consideration that in December 1981, during her first period of active service, the Veteran was treated for a mild sinus problem, and in a November 1982 service treatment record, it was noted that the Veteran's frontal and maxillary sinuses were tender to touch? The examiner should take as fact that the Veteran has had a diagnosis of sinusitis during the period on appeal.

Please provide a complete rationale for all opinions provided.

M. C. GRAHAM

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board A. M. Clark, 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.

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