Citation Nr: 1753690 Decision Date: 11/22/17 Archive Date: 12/01/17 DOCKET NO. 13-30 474 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona THE ISSUES 1. Entitlement to a higher initial disability rating for posttraumatic stress disorder (PTSD) in excess of 30 percent prior to May 7, 2015. 2. Entitlement to service connection for hypertension, including as due to service-connected PTSD and diabetes mellitus, type II. 3. Entitlement to service connection for a heart disorder, to include atrial fibrillation, including as due to herbicide exposure. 4. Entitlement to service connection for peripheral neuropathy of the right upper extremity, including as due to herbicide exposure. 5. Entitlement to service connection for peripheral neuropathy of the left upper extremity, including as due to herbicide exposure. 6. Entitlement to service connection for peripheral neuropathy of the right lower extremity, including as due to herbicide exposure. 7. Entitlement to service connection for peripheral neuropathy of the left lower extremity, including as due to herbicide exposure. ATTORNEY FOR THE BOARD E. Blowers, Counsel INTRODUCTION The Veteran, who is the appellant, had active service from September 1966 to June 1970. This matter came before the Board of Veterans' Appeals (Board) on appeal from a March 2013 rating decision of the RO in Phoenix, Arizona. The issues on appeal were previously before the Board in July 2015, where, in pertinent part, the remaining issues on appeal were remanded for additional development. While cognizant of its responsibilities under Stegall v. West, 11 Vet. App. 268 (1998), as the instant decision fully grants all of the remaining issues on appeal, the Board need not address Stegall compliance at this time. The Veteran has appealed from the initial rating assigned for the service-connected PTSD. In Fenderson v. West, 12 Vet. App. 119, 125-26 (1999), the United States Court of Appeals for Veterans' Claims (Court) addressed a similar appeal and directed that such appeal of the initial rating assigned following a grant of service connection was specifically not a claim for an increased disability rating. The Court also directed that separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. An appellant is presumed to be seeking the maximum possible benefit for the rating appealed. See A.B. v. Brown, 6 Vet. App. 35 (1993). In A.B., the Court recognized that a claimant may limit the claim or appeal to the issue of entitlement to a particular disability rating which is less than the maximum allowed by law for a particular service-connected disability. Id. at 39. During the course of this appeal, in a March 2016 rating decision, the RO granted a staged higher initial disability rating of 70 percent for the service-connected PTSD from May 7, 2015, which was a partial grant as to the PTSD rating issue on appeal. In multiple subsequent letters from the Veteran's former representative, the representative advanced satisfaction with the 70 percent disability rating, but argued that the 70 percent disability rating was warranted for the entire initial rating period on appeal. While the Veteran is no longer represented by that attorney, no subsequent statements by the Veteran indicate a desire to seek a disability rating in excess of 70 percent for the service-connected PTSD, the evidence does not suggest a rating in excess of 70 percent is warranted for the service-connected PTSD, and the Veteran has not indicated that any of the rating criteria for a rating in excess of 70 percent are met or approximated for the service-connected PTSD. The instant matter is a Veterans Benefits Management System (VBMS) appeal. The Board has reviewed both the VBMS and the "Virtual VA" files so as to insure a total review of the evidence. This appeal has been advanced on the Board's docket pursuant to 38 U.S.C. § 7107(a)(2) (2012) and 38 C.F.R. § 20.900(c) (2017). FINDINGS OF FACT 1. From February 7, 2012, the date of claim for service connection, until May 7, 2015, the severity, frequency, and duration of the symptoms of the service-connected PTSD more nearly approximated occupational and social impairment with deficiencies in most areas. 2. The Veteran is currently diagnosed with hypertension. 3. The hypertension is caused by the service-connected PTSD. 4. The Veteran is currently diagnosed with the heart disorder of atrial fibrillation, which is a form of supraventricular arrhythmia. 5. The atrial fibrillation is proximately due to or the result of the service-connected hypertension. 6. The Veteran is currently diagnosed with peripheral neuropathy of both upper extremities and both lower extremities. 7. During service the Veteran served in the Republic of Vietnam so is presumed to have been exposed to the herbicide Agent Orange. 8. The currently diagnosed peripheral neuropathy of both upper extremities and both lower extremities is related to the Agent Orange exposure. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, from February 7, 2012, the date of claim for service connection, until May 7, 2015, the criteria for a disability rating of 70 percent, but no higher, for the service-connected PTSD have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.130, Diagnostic Code 9411 (2017). 2. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for hypertension, as secondary to the service-connected PTSD, have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310, 3.326 (2017). 3. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for the heart disorder of atrial fibrillation, as secondary to the service-connected hypertension, have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310, 3.326 (2017). 4. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for peripheral neuropathy of the right upper extremity have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.313, 3.326 (2017). 5. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for peripheral neuropathy of the left upper extremity have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.313, 3.326 (2017). 6. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for peripheral neuropathy of the right lower extremity have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.313, 3.326 (2017). 7. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for peripheral neuropathy of the left lower extremity have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.313, 3.326 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and to Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.326(a). The Court issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. As the instant decision grants service connection for hypertension, atrial fibrillation, and peripheral neuropathy of all four extremities, and grants a higher initial disability rating of 70 percent for PTSD for the entire relevant rating period on appeal, the Board need not further discuss the duties to notify and assist. Higher Initial Disability Rating for PTSD Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2017). Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Under Diagnostic Code 9411, a 30 percent rating will be assigned for a mental disability which is productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating will be assigned for a mental disability which is productive of occupational and social impairment with reduced reliability and productivity due to symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks occurring more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material or forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating will be assigned for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and an inability to establish and maintain effective relationships. A 100 percent rating will be assigned for total occupational and social impairment due to symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, a persistent danger of hurting herself or others, an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130. The Global Assessment of Functioning (GAF) is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994). A score of between 1 and 10 is defined as persistent danger of severely hurting self or others (e.g., recurrent violence) or persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death. A score of between 11 and 20 conveys that there is some danger of hurting self or others (e.g., suicide attempts without clear explanation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely incoherent or mute). A score of between 21 and 30 is assigned when behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). A score of between 31 and 40 denotes some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A score of between 41 and 50 denotes serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning, (e.g., no friends, unable to keep a job). A score of between 51 and 60 reflects moderate difficulty in social, occupational, or school functioning. A score of between 61 and 70 indicates the presence of mild symptoms and/or some difficulty in social, occupational, or school functioning, but a generally satisfactory level of functioning. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996). The Secretary of VA, acting within his authority to adopt and apply a schedule of ratings, chose to create one general rating formula for mental disorders. 38 U.S.C. § 1155; see 38 U.S.C. § 501 (2012); 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 psychiatric disorders, there can be no doubt that the Secretary of VA anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over-inclusive. The Secretary's use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. This construction is not inconsistent with Cohen v. Brown, 10 Vet. App. 128 (1997). See Mauerhan v. Principi, 16 Vet. App. 436, 442 (1992). The evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). See 38 C.F.R. § 4.126. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. The schedular rating criteria rate by analogy psychiatric symptoms that are "like or similar to" those explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. The Federal Circuit has embraced the Mauerhan interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (2013), the Federal Circuit held that VA "intended the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based upon their objectively observable symptoms." The Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." See also Bankhead v. Shulkin, No. 15-2404 (Vet. App., Mar. 27, 2017) (indicating that the Board should consider the severity, frequency, and duration of the signs and symptoms of a mental disorder when determining the appropriate rating). As discussed above, the Veteran had requested a 70 percent disability rating for the service-connected PTSD for the entire initial rating period on appeal. Having reviewed all the evidence of record, both lay and medical, the Board finds that, for the entire initial rating period on appeal, from February 7, 2012 to May 7, 2015, the severity, frequency, and duration of the symptoms of the service-connected PTSD have more nearly approximated occupational and social impairment with deficiencies in most areas, to warrant a 70 percent schedular disability rating. Per the February 2012 claim for service connection for PTSD, the Veteran was married and divorced on four occasions (in 1970, 1983, and 2012, with the third date of divorce unknown). At a VA PTSD examination in March 2012, the Veteran reported that a fourth marriage had just ended due to "legal struggles." Further, in the report it was noted that the Veteran had been arrested and served prison time for money laundering. The Veteran discussed having nightmares and sleep problems, and also advanced having past difficulties with aggression. Other symptoms reported or observed during the examination in March 2012 include avoidance of situations reminding of past trauma (like or similar to disturbances of motivation and mood), social isolation (like or similar to difficulty establishing and maintaining effective work and social relationships), irritability or outbursts of anger (like or similar to disturbances of motivation and mood), depressed mood, chronic sleep impairment, and disturbances of motivation and mood. A May 2015 private PTSD examination report reflects the Veteran's report that the PTSD resulted in four divorces and other social impairment. The private examiner stated that the PTSD symptoms resulted in an "extensive history of being unable to sustain employment." Upon examination, symptoms, other than those already discussed above, included feelings of detachment or estrangement from others (like or similar to an inability to establish and maintain effective relationships), difficulty concentrating, hypervigilance (like or similar to disturbances of motivation and mood), weekly panic attacks, impairment of short and long term memory, difficulty adapting to stressful circumstances, including work or a work-like setting, and an inability to establish and maintain effective relationships. At the conclusion of the examination, the private examiner noted that the severity of the symptoms caused the Veteran to be mostly socially isolated, other than interacting with his children. In a corresponding August 2015 summary letter to the May 2015 private examination, the private examiner opined that the Veteran had a long history of untreated PTSD symptoms that disrupted the Veteran's "life socially, occupationally, and financially, which resulted in four broken marriages, numerous financial hardships, and disruption to other relationships both personal and professional for many years." After a review of all the evidence, lay and medical, the Board finds that, from February 7, 2012, the date of claim for service connection, until May 7, 2015, when a 70 percent rating has already been granted, the severity, frequency, and duration of the symptoms of the service-connected PTSD more nearly approximated occupational and social impairment with deficiencies in most areas, as required for a higher initial rating of 70 percent under Diagnostic Code 9411. Per the August 2015 private mental health summary letter, the Veteran appeared to have a long history of severe PTSD symptoms that had a severely negative impact on the Veteran's social and occupational functioning dating well before the date of claim. While the Board notes that the Veteran has displayed a number of symptoms at the 30, 50, and 70 percent schedular rating criteria, after having considered all the relevant evidence of record, and resolving all reasonable doubt in favor of the Veteran, a disability rating of 70 percent is warranted for the service-connected PTSD for the rating period remaining on appeal, from February 7, 2012 until May 7, 2015. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. The appeal for a higher initial disability rating for the service-connected PTSD is fully granted in this Board decision. As discussed above, in various statements during the course of this appeal, the Veteran's prior representative advanced that 70 a percent disability rating for the entire initial rating period on appeal would satisfy the PTSD rating issue; thus, this Board decision is a full grant of the benefits sought on appeal as to the initial PTSD disability rating. This is distinguished from a case where a veteran does not express satisfaction with a partial increased rating during an appeal that is less than the maximum schedular rating. See A.B. at 39 (recognizing that a claimant may limit the claim or appeal to the issue of entitlement to a particular disability rating which is less than the maximum allowed by law for a particular service-connected disability). The Board finds the waiver of the remaining aspects of the appeal for increased disability ratings was knowing, intelligent, and consistent with the evidence of record. Because a 70 percent initial disability rating for PTSD is being granted for the period from February 7, 2012 until May 7, 2015, the Veteran has limited this appeal in both extent and time by withdrawing the aspects of the appeal that encompassed a higher disability rating in excess of 70 percent for any period. See 38 C.F.R. § 20.204 (2017) (providing that an appellant may withdraw an issue at any time before the Board issues a final decision). For these reasons, any question of a higher initial disability rating in excess of 70 percent for the service-connected PTSD for any period is rendered moot, with no remaining questions of law or fact to decide. See 38 U.S.C. § 7104 (2012); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (where the law is dispositive, the claim must be denied due to a lack of legal merit). Extraschedular Referral Consideration The Board has also considered whether referral for an extraschedular rating is warranted for the service-connected PTSD. Ratings shall be based as far as practicable upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular ratings are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extraschedular rating commensurate with the average earning capacity impairment due exclusively to the service connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). As discussed above, concerning the appeal for a higher initial disability rating for PTSD in excess of 30 percent prior to May 7, 2015, the Veteran has limited this appeal in both extent and time by withdrawing the aspects of the appeal that encompassed a disability rating in excess of 70 percent. As such, the full grant of benefits for the service-connected PTSD for the relevant rating period in this case also effects withdrawal of any extraschedular referral considerations. See 38 C.F.R. § 20.204. For these reasons, any question of an extraschedular disability rating for PTSD is rendered moot with no remaining questions of law or fact to decide. Finally, as the Veteran has previously been granted a total disability rating for compensation purposes based on individual unemployability due to service- connected disabilities (TDIU), the Board need not address entitlement to TDIU in the instant decision. Service Connection Law and Regulation Service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after 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). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). In this case, hypertension, atrial fibrillation, and peripheral neuropathy are "chronic diseases" under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions based on "chronic" in-service symptoms and "continuous" post-service symptoms under 38 C.F.R. § 3.303(b) apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be granted for disability that is proximately due to or the result of a service-connected disability. Service connection may also be granted for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995). Service connection may also be granted on a presumptive basis for certain diseases associated with exposure to certain herbicide agents, even though there is no record of such disease during service, if they manifest to a compensable degree any time after service, in a veteran who had active military, naval, or air service for at least 90 days, during the period beginning on January 9, 1962 and ending on May 7, 1975, in the Republic of Vietnam, including the waters offshore, and other locations if the conditions of service involved duty or visitation in Vietnam. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309(c), 3.313. This presumption may be rebutted by affirmative evidence to the contrary. 38 U.S.C. § 1113; 38 C.F.R. §§ 3.307, 3.309. The following diseases are deemed associated with herbicide exposure under VA law: AL amyloidosis, Chloracne or other acneform disease consistent with chloracne, Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes), Hodgkin's disease, Ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), Multiple myeloma, Non-Hodgkin's lymphoma, Parkinson's disease, early onset peripheral neuropathy, Porphyria cutanea tarda, Prostate cancer, Respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and Soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(c). Notwithstanding the foregoing presumption provisions for herbicide exposure, a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); see also Ramey v. Gober, 120 F.3d 1239, 1247-48 (Fed. Cir. 1997), aff'g Ramey v. Brown, 9 Vet. App. 40 (1996); Brock v. Brown, 10 Vet. App. 155, 160-61 (1997). The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his or her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Service Connection for Hypertension During the course of this appeal, the Veteran and former representative advanced that the currently diagnosed hypertension was either caused by exposure to the herbicide Agent Orange during service, or was caused or aggravated by either the service-connected PTSD or the service-connected diabetes mellitus, type II. Initially, the Board finds that the Veteran is currently diagnosed with hypertension. The report from a November 2016 VA hypertension opinion reflects that the Veteran is currently diagnosed with hypertension. Further, multiple private treatment records, including private treatment records from January 2011 and August 2015, reflect that the Veteran has been treated for hypertension. After a review of all the evidence of record, lay and medical, the Board finds that the evidence is at least in equipoise on the question of whether the currently diagnosed hypertension is due to or the result of the service-connected PTSD. VA received an April 2016 private opinion and a March 2017 addendum opinion from a "board certified physician in the field of cardiovascular medicine, who specializes in hypertension." Per the opinion reports, the private physician reviewed all of the relevant evidence of record, including service records and the Veteran's medical records. The private examiner also cited to multiple medical journal articles in both opinion reports. In both opinion reports, after considering the Veteran's medical history and the relevant medical journal articles, the private physician opined that it was at least as likely as not that the Veteran's currently diagnosed hypertension was caused or aggravated by the service-connected PTSD. In November 2016, a negative secondary service-connection opinion was rendered by a VA examiner who found that it was less likely than not that the service- connected PTSD caused or aggravated the hypertension. In the March 2017 private addendum opinion discussed above, the private physician reviewed the November 2016 opinion and found it to lack rational, to be based upon erroneous conclusions, and to lack support by the medical literature. Without commenting on the adequacy of the November 2016 VA opinion, the Board finds that this negative opinion does not outweigh the April 2016 and March 2017 private opinions, leaving the positive and negative evidence to be at least in relative equipoise. The Board finds that the evidence of record is at least in equipoise on the question of whether the Veteran's currently diagnosed hypertension is proximately due to or the result of the service-connected PTSD. A private cardiovascular physician specializing in hypertension twice opined that the service-connected PTSD caused, or at the very least aggravated, the currently diagnosed hypertension. While a VA examiner opined to the contrary, considering the criticisms of the opinion by the private physician, the Board cannot say that the negative VA opinion outweighs the positive private secondary service connection opinion. As such, resolving all reasonable doubt in the Veteran's favor, the Board finds that the criteria for service connection for hypertension as secondary to the service-connected PTSD have been met. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. As service connection has been granted on a secondary basis, there is no need to discuss entitlement to service connection on a direct, presumptive, or any other basis, as other theories of service connection have been rendered moot, leaving no question of law or fact to decide. See 38 U.S.C. § 7104 (2012). Service Connection for a Heart Disorder The Veteran and former representative have advanced that a currently diagnosed heart disorder was either caused by exposure to the herbicide Agent Orange during service, or was caused or aggravated by a service-connected disability. Initially, the Board finds that the Veteran is currently diagnosed with the heart disability of atrial fibrillation. Per the report from a February 2016 VA heart examination, a VA examiner diagnosed supraventricular arrhythmia. The VA examiner went on to clarify that the type of arrhythmia diagnosed was, specifically, atrial fibrillation. Multiple private treatment records also reflect that the Veteran has been treated for atrial fibrillation. Next, the Board notes that in February 2016, prior to the Veteran being service connected for hypertension in the instant decision, VA obtained an opinion as to whether the atrial fibrillation was due to herbicide exposure, or, if not, whether the disorder was caused or aggravated by the service-connected PTSD. While not clearly stated, the VA examiner appears to render negative direct and secondary service-connection opinions, at least in part based upon the fact that the Veteran had a number of other risk factors, to include hypertension. Further, the VA examiner noted that, per the Mayo Clinic, hypertension is one possible cause of atrial fibrillation. Considering that in the instant decision the Board grants service connection for hypertension, and when considering the other evidence of record, the Board finds by logical inference this to effectively be an opinion this it is more likely than not that the currently diagnosed atrial fibrillation was caused by the now service-connected hypertension. Considering the above, the Board finds that the evidence of record is at least in equipoise on the question of whether the Veteran's currently diagnosed heart disability of atrial fibrillation is proximately due to or the result of the now service-connected hypertension. In February 2016, a VA examiner effectively opined that the atrial fibrillation was as likely as not proximately due to or the result of the now service-connected hypertension. As such, resolving all reasonable doubt in the Veteran's favor, the Board finds that the criteria for service connection for a heart disorder of atrial fibrillation as secondary to the now service-connected hypertension have been met. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As service connection has been granted on a secondary basis (under 38 C.F.R. § 3.310), there is no need to discuss entitlement to service connection on a direct, presumptive, or any other basis, as other theories of service connection have been rendered moot, leaving no question of law or fact for the Board to decide. See 38 U.S.C. § 7104. Service Connection for Peripheral Neuropathy The Veteran asserts that the currently diagnosed peripheral neuropathy of the upper and lower extremities was caused by exposure to the herbicide Agent Orange during service. Initially, the Board finds that the Veteran is currently diagnosed with peripheral neuropathy in both upper and both lower extremities. Such diagnoses can be found in the report of the February 2016 VA peripheral nerve examination, and in multiple private treatment records received by VA during the course of this appeal. Next, the Board finds that during service the Veteran served in the Republic of Vietnam, so is presumed to have been exposed to the herbicide Agent Orange. A June 1968 service personnel record reports that in June 1968 the Veteran participated in counterinsurgency operations in the Republic of Vietnam. Further, the Veteran was previously presumptively service connected for diabetes mellitus, type II, due to Agent Orange exposure. Finally, after a review of all the evidence of record, both lay and medical, the Board finds that the evidence is at least in equipoise as to whether the currently diagnosed peripheral neuropathy of both the upper and lower extremities is related to the in-service herbicide/Agent Orange exposure. In February 2016, a VA examiner opined that it was less likely than not that the peripheral neuropathy was caused by exposure to Agent Orange based upon the medical literature; however, the VA examiner failed to consider some of the favorable evidence of record, discussed below, tying the peripheral neuropathy to herbicide exposure. As such, the Board finds the February 2016 opinion to be of little probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that an opinion based upon an inaccurate factual premise has no probative value). Multiple private treatment records tend to support a finding that the peripheral neuropathy of both upper and both lower extremities was due to Agent Orange exposure during service. A July 2014 private treatment record reflects that the Veteran was first diagnosed with peripheral neuropathy in 1999, which was well before the Veteran developed diabetes mellitus, type II. Per an April 2012 private treatment record, "a very thorough workup" was performed in an attempt to determine whether the peripheral neuropathy may be due to a cause other than Agent Orange exposure. As no other explanation was found, the private physician opined that Agent Orange exposure was likely the cause of the peripheral neuropathy. In a subsequent opinion letter to VA, the private physician opined that the Veteran had peripheral neuropathy due to Agent Orange exposure. In a June 2014 private treatment record, the private physician specifically noted that the Veteran had been exposed to Agent Orange when discussing the Veteran's peripheral neuropathy. After examining the Veteran, the private physician opined that Agent Orange exposure was a major contributor, if not the sole cause, of the Veteran's peripheral neuropathy. In a subsequent July 2014 private treatment record, the same private physician stated that Agent Orange exposure was the probable etiology of the peripheral neuropathy. A private treatment record printed in March 2015 (actual record date unknown) noted that the etiology of the Veteran's peripheral neuropathy was likely exposure to Agent Orange because, at that time, the Veteran had not yet developed diabetes and there was no other obvious cause of the peripheral neuropathy. In an undated private treatment record, a private physician noted that the Veteran was exposed to Agent Orange and had no other medical problems that could account for the peripheral neuropathy. As such, the private physician stated that, "it is difficult for me to think that Agent Orange is not responsible for the peripheral neuropathy." The Veteran is currently diagnosed with peripheral neuropathy of both the upper and lower extremities, and during service the Veteran was exposed to the herbicide Agent Orange. At least two private physicians who have treated the Veteran for the peripheral neuropathy symptoms have found that that the Veteran's currently diagnosed peripheral neuropathy was related to Agent Orange exposure. Such opinions were rendered after examination of the Veteran and review of the relevant medical records turned up no other possible causes for the peripheral neuropathy. As such, resolving reasonable doubt in the Veteran's favor, the Board finds that peripheral neuropathy of the right and left upper, and right and left lower, extremities was incurred in active service. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for hypertension, as secondary to the service-connected PTSD, is granted. Service connection for the heart disorder of atrial fibrillation, as secondary to the service-connected hypertension, is granted. Service connection for peripheral neuropathy of the right upper extremity is granted. Service connection for peripheral neuropathy of the left upper extremity is granted. Service connection for peripheral neuropathy of the right lower extremity is granted. Service connection for peripheral neuropathy of the left lower extremity is granted. ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs