SAMPLE CASE #2


Citation Nr: 0201162
Decision Date: 02/05/02 Archive Date: 02/11/02

DOCKET NO. 94-41 822 ) DATE

On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas

THE ISSUES
1. Entitlement to service connection for liver cirrhosis with portal hypertension and hepatic encephalopathy.
2. Entitlement to service connection for anemia.
3. Entitlement to service connection for hypersplenism.
4. Entitlement to service connection for Non-Hodgkin's lymphoma.
5. Entitlement to service connection for diabetes mellitus.
6. Entitlement to service connection for chloracne.
7. Entitlement to service connection for porphyria cutanea tarda (PCT).
8. Entitlement to service connection for peripheral neuropathy.
9. Entitlement to service connection for residuals of dental trauma for the purpose of obtaining Department of Veterans Affairs (VA) outpatient dental treatment.

REPRESENTATION

Veteran represented by: Disabled American Veterans

ATTORNEY FOR THE BOARD
K. Conner, Counsel

INTRODUCTION

The veteran had active naval service from October 1966 to June 1970.

This matter comes to the Board of Veterans' Appeals (Board) from rating decisions of the VA Houston Regional Office (RO) which denied service connection for liver cirrhosis with portal hypertension and hepatic encephalopathy, anemia, hypersplenism, Non-Hodgkin's lymphoma, diabetes mellitus, chloracne, PCT, and peripheral neuropathy. In October 1996, the Board remanded the matter for additional development of the evidence. While the matter was in remand status, by February 1999 rating decision, the RO denied service connection for a dental condition for the purpose of receiving VA outpatient dental treatment.

FINDINGS OF FACT

1. Liver cirrhosis with portal hypertension and hepatic encephalopathy, anemia, hypersplenism, Non-Hodgkin's lymphoma, diabetes mellitus, chloracne, and PCT were not shown in service or for many years thereafter.

2. The preponderance of the most probative evidence of record indicates that the veteran's liver cirrhosis with portal hypertension and hepatic encephalopathy, anemia, and hypersplenism, are not causally related to his active service, any incident therein, including claimed exposure to Agent Orange, or to any service-connected disability.

3. The veteran had service aboard a ship in the waters offshore Vietnam during the Vietnam era and the record contains a current diagnosis of diabetes mellitus.

4. The clear weight of the medical evidence of record supports the conclusion that the veteran does not now have Non-Hodgkin's lymphoma or chloracne.

5. The veteran does not have an adjudicated compensabl service-connected dental condition, a service-connected noncompensable dental condition determined to be the result of combat wounds or other service trauma, he was not detained or interned as a prisoner of war, he does not have a dental condition clinically determined to be complicating a medical condition currently being treated by VA, and he is not a Chapter 31 vocational rehabilitation trainee.

CONCLUSIONS OF LAW

1. Diabetes mellitus may be presumed to have been incurred during the veteran's active naval service. 38 U.S.C.A. 1110, 5107 (West 1991 & Supp. 2001); 38 C.F.R. 3.303, 3.307, 3.309 (2001).

2. Liver cirrhosis with portal hypertension and hepatic encephalopathy, anemia, hypersplenism, Non-Hodgkin's lymphoma, chloracne, and PCT were not incurred in or aggravated during his active service, may not be presumed to have been so incurred, nor are such disabilities causally related to or aggravated by any service-connected disability. 38 U.S.C.A. 1110, 5107 (West 1991 & Supp. 2001); 38 C.F.R. 3.303, 3.307, 3.309, 3.310 (2001).

3. The criteria for entitlement to service connection for a dental condition, including for the purpose of obtaining VA outpatient dental treatment, have not been met. 38 U.S.C.A. 1110, 5107 (West 1991 & Supp. 2001); 38 C.F.R. 3.303, 3.381 (1998); 38 C.F.R. 3.381, 4.149, 4.150, 17.161 (2001).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

Initially, the Board concludes that VA has fully met its obligations to the veteran under the Veterans Claims Assistance Act of 2000 (VCAA) and its implementing regulations with respect to the claims of service connection for liver cirrhosis with portal hypertension and hepatic encephalopathy, anemia, hypersplenism, diabetes mellitus, Non-Hodgkin's lymphoma, chloracne, and PCT, as well as the claim for VA outpatient dental treatment. See 38 U.S.C. 5102, 5103, 5103A, and 5107 (West Supp. 2001).

Regarding VA's duty to notify the veteran of any information and evidence needed to substantiate and complete a claim, the Board notes that the RO has repeatedly informed him of the reasons and bases for the denial of his claims and the types of evidence which would substantiate his claims. The Board concludes the discussions in the rating decisions, the Statements of the Case, the Supplemental Statements of the Case, letters from the RO and the Board, and the Board's October 1996 remand, were sufficient to comply with VA's notification requirements. 38 U.S.C. 5102 and 5103 (West Supp. 2001).

Second, VA has a duty to assist the veteran in obtaining evidence necessary to substantiate the claims. 38 U.S.C. 5103A (West Supp. 2001). In this case, the RO has requested all relevant treatment records identified by the veteran. Also of record are his service medical and dental records. In addition, the veteran has been afforded numerous VA medical examinations in connection with his claims, and VA has also obtained an opinion from its Chief Public Health and Environmental Hazards Officer, as well as an independent medical expert. After reviewing the extensive evidence in the veteran's two sizable claims folders, the Board finds that there is more than sufficient evidence of record to decide his claims properly. Additional medical examinations or opinions are simply not necessary.

In view of the foregoing, the Board finds that VA has fully satisfied its duty to the appellant under the VCAA. As the RO fulfilled the duty to assist and notify, and because the change in law has no material effect on adjudication of his claims, the Board finds that it can consider the merits of the claims service connection for liver cirrhosis with portal hypertension and hepatic encephalopathy, anemia, hypersplenism, diabetes mellitus, Non-Hodgkin's lymphoma, chloracne, and PCT, as well as the claim for VA outpatient dental treatment, without prejudice to him. Bernard v Brown, 4 Vet. App. 384 (1993).

In sum, the Board finds that further development and expending of VA's resources is not warranted. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided).

I. Factual Background

The veteran's service medical records are entirely negative for any notation of liver cirrhosis, portal hypertension, hepatic encephalopathy, anemia, hypersplenism, Non-Hodgkin's lymphoma, diabetes mellitus, chloracne, PCT, or peripheral neuropathy. At his May 1970 service separation medical examination, his skin, lymphatics, neurologic system, abdomen, vascular system, and endocrine system were normal on clinical evaluation.

The veteran's DD Form 214N, Armed Forces of the United States Report of Transfer or Discharge, indicates that he had three years, five months, and 13 days of foreign and/or sea service. He was also awarded, inter alia, the Vietnam Service Medal.

In August 1989, he filed a claim for nonservice-connected pension benefits, claiming that he was totally disabled due to cirrhosis of the liver. In support of his claim, the RO obtained private treatment records he had identified, dated from August 1988 to February 1990.

In pertinent part, these records show that in July 1989, the veteran was hospitalized in connection with his complaints of swollen feet, abdominal discomfort, and shortness of breath. A history of chronic alcoholism for several years was noted. The diagnoses on discharge were alcoholic cirrhosis of the liver and hypochromic anemia. Also submitted was a July 1989 Medical Evaluation Form noting that the veteran currently had cirrhosis of the liver with ascites, anemia, and elevated serum ammonia with an antecedent of chronic alcoholism for several years. This form also contains an opinion to the effect that the veteran was permanently and totally disabled r due to his disability.

In January 1990, the veteran was again hospitalized with continued symptoms. On admission, a long history of alcohol abuse was noted, although the veteran's family indicated that he had quit drinking in October 1989. Consultation with a gastroenterologist resulted in an impression of chronic liver disease with hepatic failure manifesting as signs and symptoms of portosystemic encephalopathy. The diagnoses on discharge were liver failure, alcoholism, and gastrointestinal bleeding.

Records from the Social Security Administration show that the veteran was awarded disability benefits, effective June 1, 1989.

By June 1990 rating decision, the RO awarded nonservice- connected pension benefits to the veteran, effective February 12, 1990. The veteran appealed the effective date assigned by the RO, claming that he was entitled to an effective date in August 1989.

In support of his appeal, the veteran submitted a September 1990 letter from Gustavo A. Diaz, M.D., who indicated that he had been the veteran's attending physician since July 1989. He indicated that he veteran had alcoholic cirrhosis of the liver with ascites, as well as hepatic encephalopathy. He indicated that the veteran had been totally disabled since July 1989.

By January 1991 rating decision, the RO granted an earlier effective date of August 11, 1989, for the veteran's nonservice-connected pension benefits.

In February 1991, the veteran filed a claim of service connection for non-Hodgkin's lymphoma, which he claimed he had developed as a result of exposure to Agent Orange in Vietnam. In support of his claim, he submitted an excerpt from a medical treatise indicating that the signs and symptoms of non-Hodgkin's lymphoma included enlargement of the liver and spleen, abdominal pain, bleeding from the intestines, and vomiting of blood. Also submitted by the veteran was a VA Agent Orange Brief noting that Vietnam veterans were at an increased risk of developing non- Hodgkin's lymphoma. The veteran also submitted January 1991 Statements of Attending Physicians indicating diagnoses of chronic alcoholism, chronic liver failure, and alcoholic cirrhosis of the liver.

In August 1991, the veteran filed a claim of service connection for PCT, claiming that such condition was secondary to his exposure to Agent Orange in Vietnam. He also reiterated his contention that he had non-Hodgkin's lymphoma due to Agent Orange exposure. In support of his assertions, he submitted an excerpt from the American Medical Association Encyclopedia of Medicine which noted that the signs and symptoms of non-Hodgkin's lymphoma included abdominal bleeding, vomiting of blood, and enlargement of the liver and spleen. He also submitted copies of various medical records previously submitted in which he highlighted notations of his symptoms such as vomiting of blood.

In December 1991, the veteran submitted a statement in which he appeared to raise claims of service connection for cirrhosis of the liver and peripheral neuropathy, both of which he claimed were also due to exposure to Agent Orange in Vietnam. In support of these claims, he submitted an excerpt from an unspecified medical treatise indicating that although the primary cause of cirrhosis of the liver was the chronic ingestion of alcohol, it was also associated with exposure to some chemical carcinogens.

Also submitted by the veteran was a January 1992 Statement of Attending Physician in which Dr. Diaz indicated that the veteran had severe cirrhosis of the liver, severe and chronic alcoholism, and severe peripheral neuropathy, secondary to his chronic alcoholism.

The RO thereafter obtained additional medical records showing, inter alia, that the veteran continued to receive treatment for alcoholic cirrhosis of the liver. In January 1990, he was diagnosed with hepatic encephalopathy. In March 1991, he was hospitalized with upper gastrointestinal bleeding. A long history of alcoholic hepatitis and cirrhosis with recurrent upper gastrointestinal bleeding was noted. Following additional diagnostic testing and further treatment, the veteran's physician, Carleton K. Thompson, M.D., a private gastroenterologist, indicated that the diagnoses were (1) upper gastrointestinal bleeding, secondary to (2); (2) esophageal varices, secondary to (3); (3) portal hypertension, secondary to (4); (4) cirrhosis, secondary to (5); (5) history of excessive alcohol intake until January 1990; (6) anemia, secondary to gastrointestinal bleeding; and (7) hypersplenism, secondary to portal hypertension.

In connection with his claims, the veteran was afforded VA medical examinations in March 1992. On VA Hodgkin's examination in March 1992, the veteran reported that although he had never been diagnosed with non-Hodgkin's lymphoma, he nonetheless felt that he had the condition due to Agent Orange exposure. In that regard, he indicated that he had served aboard a ship in the Tonkin Gulf during the Vietnam era, but had never had a mission inside the country. Following physical examination and diagnostic testing, the diagnosis was no evidence of non-Hodgkin's lymphoma.

On VA liver and gastrointestinal examination in March 1992, the veteran reported that he had been diagnosed with alcoholic liver disease in July 1989 and had been hospitalized on several occasions since that time for treatment of complications such as gastrointestinal bleeding, hypersplenism, and hepatic encephalopathy. He also indicated that he had been diagnosed with diabetes mellitus in November 1991. The veteran reported that he drank heavily from 1966 to 1970, and that he stopped drinking in July 1989. The diagnoses were liver cirrhosis, secondary to excessive alcohol intake up until January 1990, with history of hepatic encephalopathy; history of upper gastrointestinal bleeding from esophageal varices, secondary to portal hypertension, secondary to liver cirrhosis.

On VA neurological examination in March 1992, the examiner indicated that there was currently no objective evidence of peripheral neuropathy.

In August 1992, the veteran submitted a claim of service connection for diabetes mellitus. In support of his claim, he submitted a November 1991 private hospitalization summary showing that he had been hospitalized because of pain in the right inguinal area. During treatment for that condition, it was discovered that veteran had diabetes mellitus. The diagnoses on discharge were right inguinal area abscess and diabetes mellitus.

In January 1993, the veteran claimed entitlement to service connection for hepatic encephalopathy and anemia, which he claimed were secondary to exposure to Agent Orange. He also indicated that he had cirrhosis of the liver, hepatic encephalopathy, peripheral neuropathy, diabetes mellitus, anemia, hepatic failure, hypersplenism, and portal hypertension, as a result of exposure to Agent Orange. He claimed that he had recently undergone "medical testing for Dioxin exposure due to Agent Orange." In support of his assertion, he submitted a January 1993 report from the American Institute of Toxicology. This report showed that the veteran underwent testing in December 1992 which was positive for dioxin at a concentration of "0.062 ng/ml." The bottom part of the report noted that "[e]stimated serum levels of TCDD consistent with production of clinically observable chloracne has been reported to be in excess of 100 ppt."

Also submitted by the veteran was a February 1993 letter from Dr. Thompson who indicated that he thought the veteran's liver disease probably had three etiologies. First, he noted that the veteran "obviously had significant exposure to Agent Orange" which he indicated may have made the liver more susceptible to damage from alcohol which he stopped using in 1989 or 1990. In addition, Dr. Thompson indicated that further damage could have come from his the veteran's diabetes. He also indicated that the veteran's peripheral neuropathy could be related to Agent Orange exposure and aggravated by alcohol and diabetes mellitus. He indicated that "[e]ven though [the veteran's] medical problems seem to have a multifactorial etiology, I would think the initial insult for both the liver disease and the peripheral neuropathy is probably related to [his] service exposure to Agent Orange."

By April 1993 rating decision, the RO denied service connection for non-Hodgkin's lymphoma, peripheral neuropathy, diabetes mellitus, esophageal varices secondary to portal hypertension, and cirrhosis of the liver. The veteran's claim of service connection for PCT was deferred. He was notified of the RO's decision in a detailed May 1993 letter and he appealed.

In support of his appeal, he submitted an April 1993 Amended Decision on Appeal from the Agent Orange Administration, which found that the veteran was eligible to participate in the Agent Orange Payment Program. Specifically, it was noted that newly submitted evidence showed that the veteran had served in "search and rescue" missions in the inland waters of Vietnam.

Also submitted was a June 1993 letter from Dr. Diaz who indicated that the veteran had been diagnosed with cirrhosis of the liver in July 1989, and since had developed peripheral neuropathy due to alcoholism. He also noted that the veteran had contracted diabetes mellitus in November 1991 and was currently undergoing treatment for that condition. Finally, he noted that toxicology testing performed in December 1992 had shown "significant exposure to the chemical Dioxin" and that "[p]ossibility exists that his [unspecified] medical conditions could be related to his exposure to the chemical dioxin (Agent Orange)."

In a June 1993 Statement of Attending Physician, Dr. Diaz indicated that the veteran had cirrhosis of the liver, chronic alcoholism, peripheral neuropathy secondary to chronic alcoholism, and diabetes mellitus.

In October 1993, the veteran again requested service connection for PCT. In support of his claim, he submitted an October 1993 Statement of Attending Physician from Dr. Diaz showing a diagnosis of severe PCT and an October 1993 private laboratory report, apparently showing increased levels of PCT.

In May 1994, the veteran underwent VA general surgical examination at which it was noted that December 1992 blood studies were positive for dioxin contamination. It was also noted that the veteran had developed toxic porphyrinuria and that a copy of the October 1993 blood study was of record. It was also noted that the veteran had reported positive burning neuropathy in the feet from diabetic neuropathy in the Summer of 1992. The diagnoses were cirrhosis of the liver, ongoing anemia, porphyrinuria diagnosed by blood test in October 1993, non-Hodgkin's lymphoma felt to be ruled out, hypersplenism with enlarged spleen diagnosed in 1990 by CT scan following encephalopathy and multiple biopsies of the liver.

On VA general medical examination in May 1994, the veteran claimed he had "considerable exposure" to Agent Orange in service and that in 1984, he began to develop some problems with dizziness, weakness, and skin problems such as black heads and pimples. He indicated that he had since been diagnosed with diabetes, cirrhosis, and portal hypertension. He also reported that he had "extensive work-up on several different occasions" for porphyria and dioxin and had been found to have elevated levels of dioxin and positive porphyria. On examination, the veteran's face exhibited blackheads and folliculitis; there was also folliculitis on the neck and upper trunk and a slight indication of jaundice. The diagnoses were anemia secondary to liver cirrhosis, chronic blood loss due to esophageal varix, and skin disorder secondary to porphyrin.

In September 1994, the veteran submitted a claim of service connection for chloracne, which he indicated was "a acne- like skin disorder characterized by exposure to TCDD (agent orange) or related chemicals." In support of his claim, he submitted a copy of the May 1994 VA medical examination report showing a diagnosis of skin disorder secondary to porphyrin.

By May 1995 rating decision, the RO denied service connection for liver cirrhosis with portal hypertension and hepatic encephalopathy, anemia, hypersplenism, Non-Hodgkin's lymphoma, diabetes mellitus, chloracne, PCT, and peripheral neuropathy. The veteran appealed the RO's determination.

In support of his appeal, he submitted excerpts from numerous medical and scientific treatises regarding, inter alia, the effects of exposure to dioxin. A February 1986 article from the Journal of Biochemistry entitled "Porphyria Cutanea Tarda, or the Uropophyinogen Decarboxylase Deficiency Diseases," noted that four etiologic agents had been implicated in this condition: alcohol, oral estrogen, halogenated aromatic hydrocarbons, and iron. It was also noted that the toxic effects of TCDD included chloracne, liver damage, and hepatic porphyria in experimental animals and perhaps also in humans.

Also submitted was a June 1995 letter from Dr. Diaz who indicated that he had reviewed the veteran's medical records and had concluded that, although the veteran had been diagnosed with conditions not related to his military service, he also manifested conditions which were associated with his exposure to Agent Orange. Dr. Diaz, however, did not identify the "conditions" manifest in the veteran which he felt may be associated with Agent Orange exposure. Dr. Diaz also noted that "[a]ccording to the Service Medical Records of [the veteran], I find some early secondary manifestations of porphyria cutanea tarda." Again, however, Dr. Diaz failed to identify those symptoms noted in the service medical records which he felt were early manifestations of PCT. The veteran has indicated that Dr. Diaz is now deceased.

Also submitted by the veteran was a July 1995 statement, signed by 14 individuals, under the sentence "[t]he below individuals have known me since the year 1970 and therefore testify that I have had the skin disorder of chloracne since the above year."

In a March 1996 statement, the veteran claimed that his service medical records noted "early symptoms and early manifestations" of multiple conditions due to Agent Orange exposure. Specifically, he indicated that "general malaise" was noted in January 1968, which medical literature indicated was a symptom of hepatic porphyria. In addition, he indicated that he had been diagnosed with conjunctivitis in July 1969, which the medical literature indicated was a sign or symptom of exposure to Agent Orange.

In a May 1996 letter, Dr. Thompson indicated that it was his opinion that the veteran's exposure to Agent Orange was probably the "initial insult" for both his liver disease and peripheral neuropathy and that his condition was aggravated by his diabetes mellitus and alcohol use.

In November 1996, the RO contacted Dr. Thompson and asked him to provide additional information regarding his medical opinion. In response to the RO's request, in a November 1996 letter, Dr. Thompson indicated that he had been treating the veteran intermittently since March 1991, although he had not seen him for the past three years. He noted that the veteran had reported a history of exposure to dioxin during the Vietnam war and that a December 1992 laboratory study revealed a level of 62 parts per trillion of dioxin. (He noted that the laboratory indicated that a significant level was 100 parts per trillion.). It was also noted that the veteran had advised him that he had PCT and peripheral neuropathy, although he had no documentation of this. He noted that the veteran also had a history of alcohol use as well as diabetes which accounted for his claimed peripheral neuropathy and liver disease. He indicated that he had no way of knowing how important the veteran's exposure to dioxin was in his ongoing metabolic problems, particularly in light of his alcohol consumption and his diabetes mellitus.

On December 1998 VA medical examination, the veteran reported that he had been diagnosed with diabetes mellitus in 1991 and took daily oral medication. He also indicated that he was diagnosed with cirrhosis of the liver and hepatic encephalopathy in 1989, hypersplenism in 1991, and urine porphyrinuria and peripheral neuropathy in 1992. The examiner reviewed the veteran's claims folders and noted that in 1992, he had paresthesias in both feet and legs; on follow-up visit to his physician, he developed a wine-colored urine and a urine porphyrins was ordered. The examiner indicated that he could not decipher the October 1993 laboratory report or recognize the range level of the porphyrins in the urine. He also noted that the veteran had had a blood test for dioxin and it was positive about .062 parts per trillion. He indicated that according to the report, the adipose tissue of Vietnam veterans who had been exposed to Agent Orange 15 to 20 years prior was in the range of 10 to 150 parts per trillion, well below the level detected in the veteran. The veteran also claimed that in 1970, he had noticed blisters on his arms, back, and neck. Electromyography testing was conducted and revealed sensory peripheral neuropathy. In a January 1998 addendum to the examination report, the examiner indicated that the veteran had been diagnosed with cirrhosis of the liver in 1989 and peripheral neuropathy in 1992. He also noted that the veteran had a long history of alcohol intake from 1966 to 1988. Based on these factors, he indicated that the veteran's cirrhosis of the liver and peripheral neuropathy were not related to Agent Orange exposure in Vietnam.

In May 1998, the veteran submitted a claim of entitlement to outpatient dental treatment. By February 1999 rating decision, the RO denied his claim, finding, inter alia, that the record contained no evidence of a dental condition due to combat wounds or other service trauma. The veteran appealed the RO's determination, claiming that service dental records revealed evidence of treatment for dental trauma in August 1969 and January 1970.

In a May 1999 statement, a private physician indicated that the veteran had "some significant exposure to various chemicals during the war during which he served in the military." He noted that while the veteran gave some history of alcohol use in the past, he had "some Abdominal Studies reported to me from other physicians who have treated him that show some significant problems with cirrhosis inconsistent with the amount of alcohol he had consumed." He indicated that he thought that there was a "significant effective exposure of chemicals to his system and cirrhosis is otherwise, idiopathic." He also indicated that "[h]is cirrhosis may come in a significant degree from his chemical exposure."

In August 2000, the Board referred the veteran's claims folders for a VA medical expert opinion. In particular, the Board sought answers to the following questions: (1) Did the veteran manifest any of his claimed disabilities during active service or to a degree of 10 percent or more within one year of separation from service; (2) Which, if any, of the claimed disabilities does the veteran currently have; and (3) Which, if any, of the veteran's currently claimed disabilities are at least as likely as not due to exposure to Agent Orange in service. If another more likely etiology for any of the claimed disabilities can be identified, please specify.

In an August 2000 memorandum, the VA Chief Public Health and Environmental Hazards Officer responded to the Board's request for a medical expert opinion. Specifically, she indicated that she had reviewed the veteran's service medical records and it did not appear that he had manifested any of his claimed disabilities during his active naval service, nor was there any evidence of these conditions in the year following his separation from service. She further noted that based on the veteran's statements, it appeared that he had heavy alcohol consumption during military service and began experiencing significant medical problems related to liver disease, possible PCT, diabetes, and peripheral neuropathy about 1984 or later.

Regarding the second question posed by the Board, she noted that the veteran had well documented chronic liver disease with cirrhosis and associated portal hypertension, hypersplenism, esophageal varices, GI bleeding, and anemia, as well as diabetes mellitus and chronic peripheral neuropathy. She noted that the veteran may also have PCT, although definitive medical documentation was lacking regarding this disability. Finally, she indicted that she could identify no medical evidence of chloracne or non- Hodgkin's lymphoma.

With respect to the third question posed by the Board, she noted that based on current scientific information, it was her opinion that it was not possible to state that any of the veteran's claimed disabilities were at least as likely as not related to exposure to Agent Orange in Vietnam. Rather, she indicated that it was her opinion that the veteran's liver disease and any possible PCT was due to alcohol abuse. She indicated that his peripheral neuropathy was due to alcohol abuse and/or diabetes since these were well-recognized causes of the condition.

In January 2001, the Board referred the veteran's claims folder to an independent medical expert for an opinion as to the issue of service connection for PCT. In July 2001, the independent medical expert indicated that he had extensively reviewed the veteran's claims folders and had determined that nothing in such records would support a diagnosis of PCT. He noted that the veteran's service medical records did not document cutaneous manifestations of the disability while on active duty. More importantly, he indicated that the laboratory tests dated October 1993 which were referred to on multiple occasions in the record actually indicated that the veteran had normal levels of porphyrin based on the results of urine testing. He explained that the bottom half of the report was a summary of the laboratory abnormalities seen in the various clinical types of porphyrias and were not the veteran's actual test results. He explained that what had been interpreted as markedly increased levels for the veteran was in reality the porphyrin profile that one would see in a patient who actually had PCT. He noted that the record also contained a December 1998 24 hour urine porphyrin test which was also normal. In summary, he indicated that a review of the claims folder revealed no clinical or laboratory evidence of PCT.

II. Law and Regulations
Service connection may be granted for disability as a result of disease or injury incurred in or aggravated in service, but no compensation shall be paid if the disability is a result of the veteran's own willful misconduct or abuse of alcohol or drugs. 38 U.S.C.A. 1110.

Where a veteran served ninety days or more during a period of war and certain chronic diseases, including primary anemia, cardiovascular-renal disease, diabetes mellitus, encephalitis lethargica residuals, and peptic ulcers, become manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred 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.A. 1101, 1112, 1113; 38 C.F.R. 3.307, 3.309 (2001).

Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. 3.310(a) (2001). Moreover, where a service-connected disability causes an increase in, but is not the proximate cause of, a nonservice-connected disability, the veteran is entitled to service connection for that incremental increase in severity attributable to the service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995).

Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, established that the disease was incurred in service. 38 C.F.R. 3.303(d) (2001).

Additionally, a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, and has a disease listed at 3.309(e) shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. Service in the Republic of Vietnam includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. 3.307(a)(6), 3.313 (2001).

If a veteran was exposed to a herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 U.S.C.A. 1116, 38 C.F.R. 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C.A. 1113; 38 C.F.R. 3.307(d) are also satisfied: chloracne or other acneform diseases consistent with chloracne, Hodgkin's disease, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, PCT, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and certain soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. 3.309(e).

Effective July 9, 2001, Type II diabetes (also known as Type II diabetes mellitus or adult-onset diabetes) was added to a list of diseases subject to presumptive service connection under 38 C.F.R. 3.309(e). See 66 Fed. Reg. 23,166 (May 8, 2001).

The diseases listed at 38 C.F.R. 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne and PCT shall have become manifest to a degree of 10 percent or more within one year of separation, and respiratory cancers within 30 years, after the last date on which the veteran was exposed to an herbicide agent during active air service. 38 C.F.R. 3.307(a)(6)(ii).

In order to rebut this presumption of service incurrence, there must be affirmative evidence to the contrary or evidence to establish that an intercurrent injury or disease which is a recognized cause of any of the specified diseases or disabilities has been suffered between the date of separation from service and the onset of any such diseases or disabilities. 38 U.S.C.A. 1113(a). Evidence which may be considered in rebuttal of service incurrence of such disease will be any evidence of a nature usually accepted as competent to indicate the time of existence or inception of disease, and medical judgment will be exercised in making determinations relative to the effect of intercurrent injury or disease. The expression "affirmative evidence to the contrary" will not be taken to require a conclusive showing, but such showing as would, in sound medical reasoning and in the consideration of all evidence of record, support a conclusion that the disease was not incurred in service. 38 C.F.R. 3.307(d).

The Secretary has also determined that there is no positive association between exposure to herbicides and any other condition for which he has not specifically determined a presumption of service connection is warranted. See Disease Not Associated With Exposure to Certain Herbicide Agents, 59 Fed. Reg. 341-46 (Jan. 4, 1994).

Notwithstanding the foregoing, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has determined that the Veteran's Dioxin and Radiation Exposure Compensation Standards (Radiation Compensation) Act, Pub. L. No. 98-542, 5, 98 Stat. 2725, 2727-29 (1984) does not preclude a veteran from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The rationale employed in Combee also applies to claims based on exposure to Agent Orange. Brock v. Brown, 10 Vet. App. 155 (1997).

In claims for VA benefits, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. 5107(b) (West 1991 & Supp. 2001); see also Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990) (when a claimant seeks VA benefits, and the evidence is in relative equipoise, the law dictates that he or she shall prevail).

III. Analysis
Liver cirrhosis with portal hypertension and hepatic encephalopathy

The veteran claims that service connection for liver cirrhosis, portal hypertension, and hepatic encephalopathy is warranted as such conditions were incurred as a result of his exposure to Agent Orange in Vietnam.

Initially, it is noted that liver cirrhosis, portal hypertension, and hepatic encephalopathy are not among the disabilities listed in 38 C.F.R. 3.309(e). Thus, presumptive service connection for these disorders due to Agent Orange exposure is not warranted, regardless of whether or not the veteran had service on a ship in the waters off the coast of Vietnam. McCartt v. West, 12 Vet. App. 164 (1999); 38 C.F.R. 3.307, 3.309.

Accordingly, the Board has reviewed the evidence of record to determine if service connection for liver cirrhosis, portal hypertension, and hepatic encephalopathy on a direct or secondary basis is warranted. Combee and Brock, supra.

In that regard, the Board notes that the veteran's service medical records are negative for any complaints or findings of liver cirrhosis, portal hypertension, or hepatic encephalopathy. While the veteran has claimed that his service medical records show some early manifestations of conditions related to Agent Orange exposure, the Board notes that in an August 2000 opinion, a VA medical expert indicated that she had reviewed the veteran's service medical records and it did not appear that he had manifested any of his claimed disabilities during his service. The Board finds this specific and considered medical opinion rendered by an expert in the field to be far more probative than the lay assertions of the veteran and the vague, unsubstantiated letter from his private physician. (See June 1995 letter from Dr. Diaz.) See also Espiritu v. Derwinski, 2 Vet. App. 492 (1992).

The Board also notes that the post-service medical record is negative for notations of liver cirrhosis, portal hypertension, or hepatic encephalopathy until July 1989, approximately 19 years after the veteran's separation from service. Based on the foregoing, it cannot be said that liver cirrhosis, portal hypertension, or hepatic encephalopathy were present in service or manifest to a compensable degree within one year of service separation.

However, as noted above, service connection may be granted for disease diagnosed after service discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. 3.303(d). Additionally, service connection may be granted for disability which is causally related to a service- connected disease or injury. 38 C.F.R. 3.310(a); Allen, supra.

Clearly, in this case, conflicting opinions have been provided regarding the etiology of the veteran's current liver cirrhosis, portal hypertension, and hepatic encephalopathy. It is noted that some of these conflicting medical opinions were provided by the same physician. Therefore, the Board must weigh the probative value of this medical evidence. The U.S. Court of Appeals for Veterans Claims (Court) has held that "[t]he 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. . . . As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the [BVA as] adjudicators. . ." Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993).

In this case, the record shows that when he was initially diagnosed with cirrhosis of the liver in July 1989, the condition was clearly attributed to a long history of chronic alcohol abuse. Additionally, in a September 1990 letter, and January 1991 and January 1992 Statements of Attending Physician, Dr. Diaz indicated diagnoses of chronic alcoholism and alcoholic cirrhosis of the liver. Likewise, in a March 1991 hospitalization report, Dr. Thompson indicated that the veteran's cirrhosis of the liver was due to excessive alcohol intake until January 1990, with secondary portal hypertension. This medical opinion was confirmed by a VA examiner in March 1992, who also indicated a diagnosis of liver cirrhosis, secondary to excessive alcohol intake up until January 1990. It is also noted that in a January 1999 addendum to the December 1998 VA medical examination report, a VA examiner indicated that it was his opinion that the veteran's cirrhosis of the liver was not related to exposure to Agent Orange in service. Finally, the Board notes that in August 2000 memorandum, the VA Chief Public Health and Environmental Hazards Officer opined that the veteran's liver disability was not related to exposure to Agent Orange in Vietnam; rather, such condition was due to alcohol abuse.

On the other hand, in February 1993 and May 1996 letters, Dr. Thompson described the etiology of the veteran's liver disease as "multifactorial," and explained that the veteran's "significant exposure" to Agent Orange may have made his liver more susceptible to damage from alcohol and diabetes.

When asked to provide more information regarding his medical opinion in this regard, however, Dr. Thompson conceded that the veteran had a history of alcohol use as well as diabetes which accounted for his liver disease. He explained that he had based his prior opinions on the veteran's own reports of "significant" dioxin exposure and that an objective dioxin toxicology report had shown levels of exposure which were less than significant. He conceded that he had no way of knowing how important the veteran's exposure to dioxin was in his ongoing metabolic problems, particularly in light of his alcohol consumption and his diabetes mellitus. Given Dr. Thompson's clarification of the grounds on which his previous medical opinions were based, the Board finds that they are of far less probative value than the unequivocal medical opinions set forth above which were based on objective facts, rather than a history reported by the veteran.

After considering all of the evidence of record, the Board must conclude that the clear weight of the evidence is against the veteran's claim of service connection for liver cirrhosis, portal hypertension, and hepatic encephalopathy. The Board finds that the preponderance of the probative evidence of record shows that the veteran's liver cirrhosis, portal hypertension, and hepatic encephalopathy is due to a long history of alcohol abuse, not Agent Orange exposure, diabetes, or any other cause. For several reasons, the Board finds that the opinions which reach this conclusion outweigh the conflicting evidence of record, both in quantity and quality; they have far greater probative value than the opinions which attribute the veteran's liver disease to Agent Orange exposure or any other cause. These medical opinions, particularly the August 2000 VA medical opinion, are unequivocal, were based on a full and fair consideration of the material evidence, they reflect significant knowledge and skill in analysis of the pertinent data, and provide a rationale for the conclusions rendered.

By contrast, the opinions which favor the veteran's claim appear to be based on a history he provided, rather than a review of the objective medical evidence of record. For example, the May 1999 opinion from the private physician indicated that the veteran only had "some" history of alcohol use in the past, and that his cirrhosis was inconsistent with the amount of alcohol he claimed to have consumed. Thus, the physician reasoned that "[h]is cirrhosis may come in a significant degree from his chemical exposure." However, the Board notes that the contemporaneous medical records completed by the veteran's own physicians describe his alcoholism as "severe" and "chronic" and note that it extended from at least 1966 to 1990, a period of approximately twenty-four years. The weight of a medical opinion is diminished where that opinion is based on an inaccurate factual premise or an examination of limited scope. See Reonal v. Brown, 5 Vet. App. 548 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993); Guerrieri v. Brown, 4 Vet. App. 467 (1993).

In sum, the Board finds that the preponderance of the most probative evidence of record indicates that the veteran's liver cirrhosis with portal hypertension and hepatic encephalopathy is not causally related to his active service, any incident therein, including claimed exposure to Agent Orange, or to any service-connected disability. Thus, the preponderance of the evidence is against the veteran's claim of service connection for liver cirrhosis, portal hypertension, and hepatic encephalopathy. Moreover, the evidence is not so evenly balanced as to allow for the application of reasonable doubt. 38 U.S.C.A. 5107(b).

Anemia and hypersplenism
The veteran also contends that he has anemia and hypersplenism as a result of exposure to Agent Orange in Vietnam. A review of the medical records confirms that he has been diagnosed with anemia and hypersplenism. However, neither diagnosed disorder was shown in service or for many years thereafter, nor are these disorders among the diseases recognized by VA as being etiologically related to exposure to herbicide agents used in Vietnam. Thus, the presumption of exposure to Agent Orange or other herbicide agents is not available to the veteran with respect to these claims, and he cannot establish entitlement to service connection for anemia and hypersplenism on a presumptive basis. See McCartt, supra.

Even if the Board were to assume arguendo that the veteran was exposed to herbicide agents during service, there still is no basis for a grant of service connection for anemia or hypersplenism. As noted above, the disorders are not among those identified in 38 C.F.R. 3.309(e), and the Secretary of VA has determined that there is no positive association between exposure to herbicides and any other condition for which he has not specifically determined that a presumption of service connection is warranted.

Moreover, as also noted above, the veteran's anemia and hypersplenism were not diagnosed until many years after the veteran's service in Vietnam. Most significantly, there is no competent medical evidence of record suggesting a connection between any claimed in-service exposure to herbicide agents and his anemia or hypersplenism. Rather, the veteran's contentions of etiological connection are no more than unsupported speculation on his part. Again, all medical records, to include all VA and private medical records, are entirely negative for any discussion of a nexus between the veteran's anemia and hypersplenism and his claimed exposure to herbicide agents.

On the other hand, the Board notes that when the etiology of the veteran's anemia or hypersplenism is addressed in the medical evidence of record, it is consistently attributed to his chronic liver disease, a disability which the Board has concluded was not incurred in service, and is unrelated to any incident therein, including claimed exposure to Agent Orange, or to any service-connected disability. For example, a March 1991 private hospitalization summary attributes the veteran's anemia to gastrointestinal bleeding due to esophageal varices, secondary to cirrhosis of the liver. Likewise, on VA medical examination, the veteran's anemia was attributed to liver cirrhosis. Regarding his hypersplenism, in a March 1991 hospitalization report, such disorder was attributed to portal hypertension due to cirrhosis of the liver. Likewise, in an August 2000 medical opinion, a VA medical expert indicated that the veteran's hypersplenism was associated with portal hypertension due to liver cirrhosis.

Again, while the veteran has offered his own opinion that his anemia and hypersplenism are related to Agent Orange exposure, the Board again notes that the record does not indicate that he has any professional medical training or expertise. See Bostain v. West, 11 Vet. App. 124, 127 (1998) (lay testimony is not competent to establish, and therefore not probative of, a medical nexus). In contrast to the veteran's unsupported contentions, the medical evidence of record clearly indicates that there is no relationship between his current anemia and hypersplenism and his military service, any incident therein, or any service-connected disability.

Thus, the Board finds that service connection for anemia and hypersplenism is not warranted. Application of the benefit of the doubt doctrine has been considered with respect to these claims, but the Board finds that there is no approximate balance of negative and positive evidence such as to warrant its application. 38 U.S.C.A. 5107 (West 1991 & Supp. 2001). The evidence is overwhelmingly against the veteran's claims. r

Non-Hodgkin's lymphoma >br> The veteran also claims entitlement to service connection for non-Hodgkin's lymphoma. Again, he contends that he developed such disability as a result of exposure to Agent Orange in Vietnam. Having carefully examined the record in light of the applicable law, however, the Board must conclude that the evidence clearly shows that the veteran does not currently have non-Hodgkin's lymphoma.

Specifically, the veteran was afforded a VA medical examination in March 1992, at which the examiner concluded, following physical examination of the veteran and diagnostic testing, that there was no evidence of non-Hodgkin's lymphoma. Likewise, it is noted that VA's Chief Public Health and Environmental Hazards Officer reviewed the veteran's claims folder in August 2000, and concluded that the record contained no medical evidence of non-Hodgkin's lymphoma.

The Board notes that the veteran has submitted numerous excerpts from medical treatises, some of which describe the symptoms and causes of non-Hodgkin's lymphoma. Despite the fact that the record is entirely devoid of any competent diagnosis of non-Hodgkin's lymphoma, he has nonetheless argued that he does, in fact, have the condition because he was exposed to Agent Orange in service and because he has some of the symptoms delineated in those medical treatises as being indicative of non-Hodgkin's lymphoma.

However, the Board notes that the record does not establish that the veteran possesses a recognized degree of medical knowledge or training; thus, his own opinions as to medical diagnosis or causation are of no probative value. Espiritu, 2 Vet. App. at 494. The Board also notes that, without exception, the medical treatise evidence submitted by the veteran provides only generic information regarding the symptoms and causes of non-Hodgkin's lymphoma. In no way does this treatise evidence indicate that the veteran has a current diagnosis of non-Hodgkin's lymphoma or outweigh the March 1992 opinion of the VA medical examiner that the veteran does not have non-Hodgkin's lymphoma. Thus, the Board finds that this treatise evidence is of little probative value in determining whether the veteran currently has non-Hodgkin's lymphoma. See e.g., Sacks v. West, 11 Vet. App. 314, 317 (1998); see Matteren v. West, 12 Vet. App. 222 (1999).

In sum, the veteran's lay statements to the effect that he currently has non-Hodgkin's lymphoma and the generic treatise evidence regarding the causes and symptoms of that disease do not equal or outweigh the medical evidence of record which clearly indicates that the veteran does not currently have non-Hodgkin's lymphoma. As noted, Congress has specifically limited entitlement for service-connected disease or injury to cases resulting in disability. See 38 U.S.C. 1110, -Hodgkin's lymphoma in this case, service connection for that disability is not warranted. Brammer, 3 Vet. App. at 225 (in the absence of proof of a present disability there can be no valid claim).

Diabetes mellitus
As above, the veteran's service medical records are silent regarding any complaint or finding of diabetes mellitus. Likewise, the post-service medical evidence of record is negative for any notation of diabetes for many years after service separation. In fact, diabetes mellitus was not diagnosed until November 1991, about 21 years after his service separation. Moreover, there is no indication, nor does the veteran contend, that he had symptoms of diabetes on a continuous basis following his service separation. Finally, the Board observes that the competent medical evidence of record contains no indication that the veteran's diabetes mellitus is related to his active service or any service-connected disability. Thus, the Board finds that service connection for diabetes on a direct or secondary basis is not warranted. See 38 C.F.R. 3.303, 3.310 (2000).

However, effective July 9, 2001, VA added diabetes mellitus to the list of diseases presumptively connected with exposure to Agent Orange. See 66 Fed. Reg. 23,166-169 (May 8, 2001) (to be codified at 38 C.F.R. 3.309(e)). This amendment implements a decision of the Secretary that there is a positive association between exposure to herbicides used in the Republic of Vietnam during the Vietnam era and the subsequent development of Type-2 diabetes.

Under 38 CFR 3.307(a)(6)(iii), a veteran who served in Vietnam and develops a disease listed in 3.309(e) is presumed to have been exposed to herbicides. In this case, the record shows that the veteran served aboard a ship off the coast of Vietnam during the Vietnam era. Moreover, the record contains competent medical evidence of a current diagnosis of diabetes mellitus, which has shown to be compensably disabling. See 38 C.F.R. 4.119, Code 7913. Thus, the Board finds that service connection for diabetes mellitus on a presumptive basis is warranted.

Chloracne
The veteran claims that he now has chloracne which he developed in 1970 as a result of exposure to Agent Orange. However, the record in this case does not contain competent evidence of a current diagnosis of chloracne. Rather, the only notation in the medical evidence of record of chloracne is a December 1992 toxicology report noting "[e]stimated serum levels of TCDD consistent with production of clinically observable chloracne has been reported to be in excess of 100 parts per trillion." As noted above, however, this notation does not specifically refer to the veteran. Rather, the toxicology report shows that the veteran's levels were in the range of .062 parts per trillion, significantly below those individuals with clinically observable chloracne, whose range was in excess of 100 parts per trillion. Thus, this generic reference does not constitute a diagnosis of chloracne.

Again, the remainder of the competent medical evidence shows no diagnosis or indication of the presence of chloracne. In fact, when VA's Chief Public Health and Environmental Hazards Officer reviewed the veteran's claims folders in August 2000, she indicted that she could identify no medical evidence of chloracne.

As noted, the existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. 1110, 1131 (West 1991); see Degmetich v. Brown, 104 F.3d 1328 (1997). It is now well-settled that in order to be considered for service connection, a claimant must first have a disability. See also Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). In this case, there is no competent evidence of a current diagnosis of chloracne. Thus, service connection for that disability is not warranted.

In reaching its decision, the Board has considered the veteran's statements to the effect that he has had chloracne since 1970. He claims that he has witnesses who can confirm that he has had chloracne since that time. Here, the Board notes that at the time of his service separation, the veteran's skin was normal on clinical evaluation. The Board finds that the contemporaneous medical records are entitled to far more probative weight than the recollections of lay individuals of events which occurred decades previously. The negative clinical evidence from service is clearly more probative than the remote recollections of laypersons.

In any event, while the veteran (or any other lay person) is competent to testify as to observable symptoms such as a skin rash, they are not competent to provide evidence that the observable symptoms are manifestations of chronic pathology or diagnosed disability, such as chloracne. Espiritu, supra; Falzone v. Brown, 8 Vet. App. 398, 403 (1995). Likewise, the generic medical treatise evidence submitted by the veteran is insufficient to provide evidence of a current diagnosis of chloracne.

Having carefully examined all evidence of record in light of the applicable law, the Board concludes that the veteran does not currently have chloracne. Congress specifically limited entitlement for service-connected disease or injury to cases resulting in disability. See 38 U.S.C. 1110, 1131. As there is no medical evidence of current existence of chloracne, service connection for that disability is not warranted. Brammer, 3 Vet. App. at 225 (absent proof of present disability there can be no valid claim).

PCT
The veteran also claims that he currently has PCT as a result of exposure to Agent Orange in Vietnam. As noted, under applicable criteria, both service in the Republic of Vietnam during the designated time period and the establishment of one of the listed diseases is required in order to establish entitlement to the in-service presumption of exposure to an herbicide agent. McCartt, supra.

In this case, the veteran had service on a ship in the waters off the coast of Vietnam during the Vietnam era. Moreover, PCT is one of the diseases which VA has determined is associated with exposure to herbicides used in Vietnam during the Vietnam era. See 61 Fed. Reg. 57,587 (1996); 38 C.F.R. 3.307(d), 3.309(e).

In that regard, the Board also notes that the record contains competent medical evidence of a diagnosis of PCT, namely, an October 1993 Statement of Attending Physician from Dr. Diaz showing a diagnosis of severe PCT, apparently based on the results of an October 1993 private laboratory report. However, that diagnosis was discredited by an independent medical expert in a July 2001 opinion. Specifically, the independent medical expert explained that the portion of the October 1993 report apparently relied on by Dr. Diaz in diagnosing PCT was actually a summary of laboratory abnormalities seen the various clinical types of porphyrias, not the actual results pertaining to the veteran. He further indicated that he had reviewed the remaining evidence of record and had concluded that nothing in the current record indicated clinical or laboratory evidence of PCT.

The Board assigns great probative weight to the opinion of the independent medical expert. It is clear that this unbiased expert thoroughly reviewed the veteran's claims folder and specifically ruled out a diagnosis of PCT. His conclusion that the veteran does not have PCT was based on a careful review of the record, as well as on his expertise in the field. Based thereon, the Board finds that the preponderance of the evidence of record shows that the veteran does not currently have PCT.

Even if the Board were to accept Dr. Diaz's diagnosis of PCT, service connection for PCT would not be warranted. As noted above, under 38 C.F.R. 3.307(a)(6)(ii), to establish service connection for PCT on a presumptive basis, this disease must have become manifest to a degree of 10 percent or more within a year of separation from active service. Here, the earliest medical evidence in the file of PCT is in 1993, about 23 years after the veteran's service separation. Thus, as the record contains no competent medical evidence demonstrating that PCT was present in service or within the first post-service year, service connection for PCT on a presumptive basis is not be warranted. See 38 C.F.R. 3.307(a)(6)(ii).

Again, the veteran has considered the veteran's lay assertions to the effect that he has had a skin condition since 1970. However, while the veteran (or any other lay person) is competent to testify as to observable symptoms such as a skin condition, they are not competent to provide evidence that the observable symptoms are manifestations of chronic pathology or diagnosed disability, such as PCT. Espiritu, supra. Likewise, the generic medical treatise evidence submitted by the veteran is insufficient to provide evidence of a current diagnosis of PCT.

The Board has also reviewed the evidence of record to determine if service connection for PCT on a direct or secondary basis is warranted. Combee and Brock, supra. It is noted that the veteran's service medical records are negative for complaint or finding of PCT. At his naval discharge medical examination, his skin was normal on clinical evaluation and laboratory testing was negative. The first post-service diagnosis of PCT of record was in October 1993, about 23 years after service separation. Moreover, that diagnosis is outweighed by the more probative evidence of record which indicates that the veteran does not currently have PCT. Even if the Board were to accept Dr. Diaz's diagnosis, however, the record contains no competent medical evidence of a link between the veteran's PCT and his active service or any incident therein, including presumed exposure to Agent Orange, or any service-connected disability. In fact, when the etiology of the veteran's PCT is addressed in the medical evidence of record, it is attributed to alcohol abuse. (See August 2000 VA medical opinion.) In sum, absent evidence of PCT in service, for many years thereafter, or evidence linking currently-diagnosed PCT to military service, any incident therein, or any service-connected disability, service connection for PCT on a direct or secondary basis is not warranted.

In reaching its decision, the Board has considered the veteran's lay assertions with respect to diagnoses and causation, but finds that they are insufficient to establish a basis on which to grant the claim. Espiritu, supra. Likewise, the Board has carefully considered the information submitted by the veteran which he obtained from various medical treatises regarding PCT. However, this evidence is insufficient to provide evidence of a diagnosis of PCT or a link between the veteran's averment of Agent Orange exposure in service and a current diagnoses of PCT. The treatise evidence submitted is simply "too general and inconclusive" to make a link more than speculative or to outweigh the specific medical evidence in this case. See Sacks v. West, 11 Vet. App. 314 (1998).

The Board has also considered the holdings in cases such as Mattern v. West, 12 Vet. App. 222 (1999), in which the Court noted that medical treatise evidence can provide important support when combined with an opinion of a medical professional, and Wallin v. West, 11 Vet. App, 509, 514 (1998), where the Court indicated that medical treatise evidence could discuss generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least a plausible causality based on objective facts. In this case, however, as was noted above, the treatise information proffered by the veteran is not combined with a probative opinion of a medical professional that he has PCT which is related to Agent Orange exposure. Moreover, this information does not discuss generic relationships between Agent Orange exposure and PCT with a degree of certainty such that, under the facts of this case, there is plausible causality based on objective facts. In view of the foregoing, the Board must conclude that the preponderance of the evidence is against the claim of service connection for PCT.

Service connection for residuals of dental trauma for VA outpatient dental treatment
The veteran claims that he is entitled to VA outpatient dental treatment as service dental records reveal evidence of treatment for dental trauma in August 1969 and January 1970.

The veteran's service dental records show that in August 1969, tooth number 17 (a third molar) was extracted and he received post operative treatment on several subsequent occasions. In January 1970, he received post-operative treatment for a lacerated labial foramen. The remaining service medical and dental records are negative for pertinent information, including residuals of this treatment. The post-service medical evidence is entirely silent as to notation of a dental condition.

Under applicable criteria, certain dental conditions, including periodontal disease, treatable carious teeth, and replaceable missing teeth (i.e. with a bridge or denture), are not considered disabling, and may be service connected solely for the purpose of determining entitlement to VA dental examination or outpatient dental treatment under the provisions of 38 C.F.R. 17.120 or 17.123. 38 C.F.R. 4.149 (1998).

Additionally, under 38 C.F.R. 4.150, missing teeth can be service connected for compensation purposes only if the lost masticatory surface cannot be replaced by suitable prosthesis and where such loss is, inter alia, due to loss of substance of body of maxilla or mandible without loss of continuity. Code 9913. Ratings under 38 C.F.R. 4.150 apply only to bone loss through trauma or disease such as osteomyelitis and not to the loss of the alveolar process as a result of periodontal disease since such loss is not considered disabling. Id., Note.

Here, the Board notes that selected VA regulations governing dental claims were revised for purposes of clarification, effective June 8, 1999. The substance of the old and new regulations, as applicable to the veteran's claim, remains essentially the same. See 64 Fed. Reg. 30,392 (June 8, 1999) ("This amendment clarifies requirements for service connection for dental conditions. . ."). The Board finds that the change in regulation has no effect on the outcome of his claim and that neither version of the regulation is more favorable to him.

Applying the above criteria to the facts in this case, the Board finds that there is no basis for compensation for any dental disorder since both the old and new regulations clearly provide that replaceable missing teeth are not disabling conditions and may be considered service-connected solely for the purpose of determining entitlement to dental examinations or outpatient dental treatment. See 38 C.F.R. 4.149 (1998) and 62 Fed. Reg. 8,201 (to be codified at 38 C.F.R. 3.381 (2001)). No other dental condition is shown by the evidence of record.

Likewise, the Board concludes that the criteria for service connection for a dental condition, for purposes of entitlement to VA outpatient dental treatment, have not been met. Subject to the requirements set forth above, a veteran is entitled to VA outpatient dental treatment if he qualifies under one of the categories outlined in 38 U.S.C.A. 1712 and 38 C.F.R. 17.161.

A veteran will be eligible for Class I VA outpatient treatment if he has an adjudicated compensable service- connected dental condition. 38 U.S.C.A. 1712(b)(1)(A); 38 C.F.R. 17.161(a). In this case, as noted, the evidence does not show that he has an adjudicated service-connected compensable dental condition, nor does he alleged that his claimed dental condition would warrant a compensable rating under the rating schedule. See e.g., 38 C.F.R. 4.150.

Class II eligibility extends to veterans having a noncompensable service-connected dental disorder, subject to various conditions. Where a veteran has a service-connected noncompensable dental condition or disability shown to have been in existence at the time of discharge or release from active service, which took place before October 1, 1981, one- time correction of the noncompensable service-connected dental conditions may be authorized if application for such treatment was made within one year after such discharge or release. In the case of the veteran, who was discharged in June 1970, clearly his recent application is untimely under the aforementioned eligibility category.

In addition, veterans having a service-connected noncompensable dental condition determined to be the result of combat wounds or other service trauma, will be eligible for VA dental care on a Class II(a) basis. 38 U.S.C.A. 1712(b)(1)(C); 38 C.F.R. 17.161(c). For these purposes, the term "service trauma" does not include the intended effects of therapy or restorative dental care and treatment provided during a veteran's military service. VA O.G.C. Prec. Op. No. 5-97, 62 Fed. Reg. 15,566 (1997); see also 38 C.F.R. 3.306(b)(1) (2000).

In essence, the significance of a finding that a noncompensable service-connected dental condition is due to dental trauma, as opposed to other causes, is that VA provides any reasonably necessary dental treatment, without time limitation, for conditions attributable to service trauma, whereas other service-connected noncompensable dental conditions are typically subject to one-time treatment and timely application after service. 38 U.S.C.A. 1712; 38 C.F.R. 17.161.

In this case, the veteran claims that during service, he sustained "trauma" in August 1969 and January 1970, as shown in his service dental records. However, there is no indication, nor has he contended, that he sustained any external trauma to the face or mouth during service. Rather, he apparently argues that the dental treatment itself constituted "service trauma" and that he is therefore entitled to VA dental care. However, "service trauma" does not include the intended effects of therapy or restorative dental care and treatment provided during the veteran's military service. VA O.G.C. Prec. Op. No. 5-97. In any event, the record contains absolutely no competent evidence of a current dental condition due to in-service trauma or treatment, other than a missing tooth number 17. Thus, he does not meet the criteria for eligibility for Class II(a) VA outpatient dental treatment.

Class II(b) or (c) eligibility, extends to veterans having a service-connected noncompensable dental condition or disability and who were detained or interned as prisoners of war. 38 C.F.R. 17.161(d), (e). In this case, the veteran's DD Form 214 does not reflect that he was a prisoner of war, nor does he assert same. Thus, he does not meet the criteria for eligibility for either Class II(b) or (c) VA treatment.

Other categories of eligibility under 38 U.S.C.A. 1712(b) and 38 C.F.R. 17.161 include those veterans having a dental condition clinically determined to be complicating a medical condition currently being treated by VA, veterans whose service-connected disabilities are rated as totally disabling, and some veterans who are Chapter 31 vocational rehabilitation trainees. 38 C.F.R. 17.161(g), (h), (i).

However, the evidence does not show that he meets any of the other categories of eligibility of 38 U.S.C.A. 1712(b) and 38 C.F.R. 17.161. For example, he is not a Chapter 31 vocational rehabilitation trainee, nor does the objective medical evidence contain any indication whatsoever that he has a dental condition clinically determined to be complicating a medical condition now being treated by VA.

Therefore, the preponderance of the evidence is against the claim of service connection for a dental condition, including for the purpose of obtaining VA dental treatment. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable. 38 U.S.C. 5107 (West 1991 & Supp. 2001).

ORDER

Service connection for liver cirrhosis with portal hypertension and hepatic encephalopathy, anemia, hypersplenism, non-Hodgkin's lymphoma, chloracne, and PCT, is denied.

Service connection for diabetes mellitus is granted.

Entitlement to service connection for residuals of dental trauma for the purpose of obtaining VA outpatient dental treatment is denied.

REMAND
Regarding the remaining issue of service connection for peripheral neuropathy, the Board observes that the medical evidence of record is unclear as to the etiology of this disability. For example, in January 1992 and June 1993 Statements of Attending Physician, Dr. Diaz attributed the veteran's peripheral neuropathy to his chronic alcoholism. In February 1993, Dr. Thompson indicated that the veteran's peripheral neuropathy could be related to Agent Orange exposure and aggravated by alcohol and diabetes mellitus. In a December 1998 VA medical examination, a VA examiner concluded that the veteran's peripheral neuropathy was not related to Agent Orange exposure, but did not provide an alternative etiology. By August 2000 opinion, a VA medical expert concluded that the veteran's peripheral neuropathy was due to alcohol abuse and/or diabetes mellitus.

When the medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Halstead v. Derwinski, 3 Vet. App. 213 (1992). Also, under VCAA the duty to assist includes providing a medical examination or a medical opinion when such is necessary to make a decision on the claim. 38 U.S.C. 5103A(d) (West Supp. 2001).

Given the conflicting evidence outlined above, and in light of the above award of service connection for diabetes mellitus, additional development of the evidence is needed as to the claim of service connection for peripheral neuropathy.

Accordingly, the case is REMANDED for the following:
1. The RO should contact the veteran and ask him to identify the names, addresses, and approximate dates of treatment for all health care providers who may possess additional records pertinent to his claim of service connection for peripheral neuropathy. After securing any necessary authorization for the release of medical information, the RO should attempt to obtain copies of the treatment records (not already of record).

2. After the above records, if any, are secured and added to the claims folder, the veteran should be scheduled for VA medical examination for the purpose of obtaining an opinion as to the etiology of any peripheral nerve disease. The claims folders must be made available to the examiner for review in conjunction with the medical examination. The examiner should be requested to provide an opinion as to any peripheral nerve disease found on examination, whether it is at least as likely as not that any such disability is causally related to the veteran's military service, or any incident therein (including Agent Orange exposure), or any service-connected disability (including diabetes mellitus).

3. The RO should then review the claims files to ensure that all development requested above has been completed. In particular, the RO should review the requested medical report to ensure it complies with this remand. If it is not, remedial action should be taken. Stegall v. West, 11 Vet. App. 268 (1998). Also, the RO must review the claims file and ensure all notification and development required by VCAA is complete.

Then the RO should review the claim. If the benefit sought on appeal remains denied, the veteran and his representative should be provided an appropriate Supplemental Statement of the Case and an opportunity to respond. The case should then be returned to the Board.

The veteran has the right to submit additional evidence and argument on the matter remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999).

This claim must be afforded expeditious treatment by the RO. The law requires that all claims remanded by the Board or the Court for additional development or other appropriate action must be handled expeditiously. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103- 446, 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. 5101 (West Supp. 2000) (Historical and Statutory Notes).

J.F. GOUGH
Member, Board of Veterans' Appeals


RETURN TO the Main Page